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THE 



¥E¥ YORK 



MEDICAL JOUE 



A 



WEEKLY REVIEW OF MEDICINE. 



EDITED BY 



FRANK P . FOSTER, M.D. 



VOLUME XLII.' 
JULY JO DECEMBER, 1885, INCLUSIVE. 




NEW YORK: 
D. APTLETON AND COMPANY, 

1, 3, S BOND STREET. 

J 885. 



Copyright, 1885. 
By D. APPLETON AND COMPANY. 



LIST OF CONTRIBUTORS TO VOLUME XLIL 



{EXCLUSIVE OF ANONYMOUS CORRESPONDENTS). 



ABERDEIN, ROBERT, M. D., Syracuse, 
N. Y. 

ALLEN, HARRISON", M. D., Philadel- 
phia. 

ANDREWS, JOSEPH A., M. D. 
BACON, GORHAM, M. D. 
BAKER, HENRY B., M. D., Lansing, 
Mich. 

BARUCH, SIMON, M. D. 

BAUDUY, JEROME K., M. D., LL. D., 

St. Louis. 
BLACK, J. R., M. D., Newark, O. 
BLISS, H. D., M. D., Brooklyn. 
BREDIN, STEPHEN, M.D., Franklin, 

Pa. 

BRINKMAN, ALBERT, M. D., Brook- 
lyn. 

BULL, CHARLES STEDMAN, M. D. 
BURCHARD, T. HERRING, M. D. 
BURKE, W. C, Jr., M. D., South Nor- 

walk, Conn. 
BURT, STEPHEN S., M. D. 
BUSH, J. FOSTER, M. D., Boston. 
BUXTON, DUDLEY W., M. D., London. 
CARPENTER, WESLEY M., M. D. 
CARROLL, ALFRED L., M. D., Albany. 
COE, HENRY C, M. D., M. R. C. S., 

L R C P 
COOK, A. B., M. D., Louisville, Ky. 
CONWAY, JOHN R., Jr., M. D. 
CORNING, J. LEONARD, M. D. 
CRAIG, JAMES, M. D., Jersey City. 
CURRIER, ANDREW F., M. D. 
CURTIS, B. FARQUHAR, M.D. 
CURTISS, ROMAINE J., M. D., Joliet, 

111. 

DELAVAN, D. BRYSON, M. D. 
DENISON, CHARLES, M. D., Denver, 
Col. 

DENNIS, FREDERIC S., M. D. 
DIX, TANDY L., M. D., Shelbyville, Ky. 
DUANE, ALEXANDER, M.D. 
DU BOIS, HENRY A., M. D., San Ra- 
fael, Cal. 

DUNSTER, EDWARD S., M. D., Ann 
Arbor, Mich. 

ECCLES. R. G., M. D., Brooklyn. 

EDWARDS, LANDON B., M. D., Rich- 
mond, Va. 

ELLIOT, GEORGE T., M. D. 

ELSNER, H. L., M. D., Syracuse, N. Y. 

EMERSON. J. H., M. D. 

EMERY, Z. T., M. D., Brooklyn. 

FERNALD, F. G, M. D., Washington. 

FOSTER, FRANK P., M. D. 

FOWLER, GEORGE R., M.D., Brook- 
lyn. 

FRASER, E. P., M.D., Portland, Oregon. 
GARLAND, G. M., M. D., Boston. 
GARRIGUES, HENRY J., M. D. 
GARST, J., M. D., North Brookfield, 
Mass. 

GERSTER, ARPAD G., M.D. 
GITHENS, W. H. H, M. D., Philadelphia. 
GLASGOW, WILLIAM C, M. D., St. 
Louis. 



GRANGER, REED B., M. D. 
GRAUER, FRANK, M. D. 
GRAY, LANDON CARTER, M. D., 
Brooklyn. 

HALLECK, HENRY TUTHILL, M. D., 
Brooklyn. 

HALSTED, WILLIAM S., M. D. 

HAMMOND, GRyEME M., M. D. 

HAMMOND, WILLIAM A., M.D. 

HARDAWAY, W. A., M. D., St. Louis. 

HAYNES, W. H., M. D. 

HENRY, MORRIS II., M. D., LL. D. 

HOLT, L. EMMETT, M. D. 

HOOPER, FRANKLIN H., M. D., Bos- 
ton. 

HOWARD, W. T., M. D., Baltimore. 
HOWE, LUCIEN, M. D., Buffalo. 
HUBBARD, LEROY W., M. D. 
HUGHES, W. E., M. D., Philndelphia. 
HYDE, JOEL W , M.D., Brooklyn. 
INGALS, E. FLETCHER, M.D., Chicago. 
IVES, FRANK L., M. D. 
JACKSON, GEORGE THOMAS, M.D. 
JACOBI, ABRAHAM, M.D. 
JACOBY, GEORGE W., M.D. 
JARVIS, WILLIAM CHAPMAN, M. D. 
JEWETT, CHARLES, M. D., Brooklyn. 
JOHNSON, H. A.. M. IX, Chicago. 
JONES, C. N. DIXON, M. D., Brooklyn. 
KELSEY, CHARLES B., M. D. 
KESSLER, ADOLPH, M. D. 
KNIGHT, FREDERICK I., M. D., Bos- 
ton. 

KOLIPINSKI, L., M. D., Washington. 
LESTER, ELIAS, M. D., Seneca Falls, 
N. Y. 

LEUF, A. H. P., M.D., Brooklyn. 
LEWIS, E. A., M. D., Brooklyn. 
LIELL, EDWARD N., M. D. 
L1L1ENTHAL. S., M. D. 
LINCOLN, R. P., M. D. 
LLOYD, SAMUEL, M.D. 
MACKENZIE, JOHN N., M. D., Balti- 
more. 

MARKOE, FRANCIS H., M. D. 
MASON, LEWIS D., M. D., Brooklyn. 
MATTISON, J. B., M. D., Brooklyn. 
MAXSON, EDWIN R., M. D., LL. D., 

Syracuse, N. Y. 
MEARS, J. EWING, M. D., Philadel- 

M^LAURY. WILLIAM M., M. D. 
MERZBACH, JOSEPH, M. D., Brooklyn. 
MICHAEL, J. EDWIN, M. D., Baltimore. 
MILLS. G. A. 

MINOT, CHARLES SEDGWICK, M. D., 
Boston. 

MITCHELL, C. PITFIELD, M. D., M. R. 
C. S. 

MONTGOMERY, LISTON H., M. D., 
Chicago. 

MOORE, EDWIN W., M. D., Franklin, 
Pa. 

MOORE, W. OLIVER, M. D. 
MORRISON, W. H., M.D., Philadelphia. 
MOSUER, ELIZA M., M. D., Brooklyn. 



NORTHRIDGE, WILLIAM A., M. D. 

Brooklyn. 
O'DWYER, JOSEPH, M.D. 
PEABODY, GEORGE L., M. D. 
PIFFARD, HENRY G., M. D. 
PLATT, ISAAC H, M. D., Brooklyn. 
POLK, WILLIAM MECKLENBURG, 

M. D. 

POORE, CHARLES T., M. D. 
PORTER, WILLIAM H., M.D. 
RANNEY, AMBROSE L., M. D. 
READ, HENRY N., M. D., Brooklyn. 
REAMY, THAD. A., M. D., Cincinnati. 
REED, C. A. LEE, M. D., Cincinnati. 
RICE, CLARENCE C, M. D. 
ROBERTS, JOHN B., M. D., Philadel- 
phia. 

ROBERTS, MILTON JOSIAH, M. D. 
ROBERTSON, J. W., M. D., Detroit. 
ROBINSON, BEVERLEY, M. D. 
ROOSA, D. B. ST. JOHN, M. D., LL. D. 
RUSSELL, the Hon. W. H. H. 
SALMON, D. E., D. V. M., Washington. 
SEI BERT, A., M. D. 
SEW ALL, HENRY, Ph. D., Ann Arbor, 
Mich. 

SEXTON, SAMUEL, M. D. 
SIIATTUCK, F. C, M. D., Boston. 
SHUFELDT, R. W., M.D., U. S. Army. 
SHULTZ, R. G, M. D. 
SI1URLY, E. L., M.D., Detroit. 
SIMMONS, A. R., M. D., Ithaca, N. Y. 
SKENE, A. J. C, M. D., Brooklyn. 
SMITH, A. A., M. D. 
SMITH, ANDREW II., M. D. 
SMITH, AUGUSTINE. 
SP HAGUE, G., M. D., Chicago. 
SQUIBB, E. H, M. D., Brooklyn. 
STERN BERG, GEORGE M., M. D., U. S. 
Army. 

STUB, ARNOLD, M. D., Brooklyn. 
STURGIS, FREDERICK R., M. D. 
SUTHERLAND, W. P., M. D., Stillwell, 
III. 

TAYLOR, JAMES B., M. D. 

THAYER, WILLIAM HENRY, M. D., 
Brooklyn. 

THOMAS, T. GAILLARD, M. D. 

TURNER, S. S., M. D., U. S. Army. 

VANCE, AP MORGAN, M. D., Louis- 
ville. 

WALLTAN, SAMUEL S., M. D., Bloom- 
in gd ale, N. Y. 
WESTBROOK, BENJAMIN F., M. D., 
■ Brooklyn. 

WILCOX, REYNOLD W., M. D. 
WILDER, BURT G., M. I)., Ithaca, N. Y. 
WILLARD, DE F., M. D., Philadelphia. 
WILLIAMS, HERBERT F., M.D., Brook- 
lyn. 

WILLTTS, MARY, M.D.. Philadelphia. 
WILSON. J. C, M. D., Philadelphia. 
WOOLLEY, D. M., M. D.. Brooklyn. 
WRIGHT. J. WILLISTON, M. D. 
WYETH, JOHN A., M.D. 
YALE, LEROY MILTON, M. D. 



LIST OF ILLUSTRATIONS IN VOLUME XLIL 



A Dog Table 5 

The Pnysieian's Handy Cabinet Battery. . . 29 

Large Cabinet Battery 30 

Improved Iloltz Static Machine (American Pattern) 31 

Drawing the Indirect Spark from the Body of a Patient 31 

Various Forms of Electrodes employed with a Static Machine 32 

Morton's Spark Electrode 32 

Curves of Closure Contractions in Direct Stimulation of the Muscles 

in the Distribution of the Peroneal Nerve in the Leg 59 

Ranney's Spring Electrode 60 

Ranney's Diagnostic Key-board 60 

Ranney's Diagnostic Key-board as applied in Actual Use 60 

Erb's Electrode for the Examination of Farado-Cutaneous Sensi- 
bility 63 

Galvanic Battery 66 

Zinc and Chloride-of-Silver Cells. Two Illustrations 66 

Absolute Galvanometer 6" 

Phthisis and Pneumonia in their Relation to Syphilis. Three Illus- 
trations 117, 118 

A New Uterine Applicator and Dressing Forceps 138 

Electrode for Electrolysis 141 

Electrode for Electrolysis 142 

Piffard's Cautery Battery 143 



PAOB 

Instruments for Intubation of the Larynx 147 

Unilateral Temporal Hemianopsia. Three Illustrations 151, 152 

The Pathology of Acute and Chronic Coryza. Two Illustrations. 212, 213 

An Intra-vaginal Cup Syringe 249 

I Nasal Affections as a Cause of Phthisis. Ten Illustrations 

261, 262, 263, 264, 292 

Diagram of His's Embryo 397 

Thomson's Second Ovum 397 

Diagram to show the Formation of the Human Amnion 398 

Ovum supposed to be from Fifteen to Eighteen Days Old 399 

Embryo supposed to be from Fifteen to Eighteen Days Old 400 

Fragment of the Chorion 400 

A Case of Neglected Ear Disease 405 

His's Embryo L 427 

His's Embryo M 429 

W. His's Embryo M 429 

Eye Speculum. ... 483 

Cases in Orthopaedic Surgery. Eight Illustrations 511-515 

Hempstead Church 631 

The Ruins of Hempstead Church 531 

Jewett's Modification of Elliot's Obstetric Forceps 567 

Spray Tube 603 

Vulnar and Vaginal Enterocele. Four Illustrations 709,710 



THE NEW YORK MEDICAL JOURNAL, Jitly 4, 1885. 



#riomnl Communications. 



ON THE USE OF GALVANISM 
IN CHRONIC DISEASES OF THE PHARYNX * 

By E. L. SHURLY, M. D., 

DETROIT. 

You will doubtless remember that at the Congress of 
1880 I presented a short paper calling attention to the use 
of galvanism in the treatment of pharyngitis sicca. At that 
time I had had but a limited experience with this agent in 
such conditions, but since then I have used galvanism in a 
number of cases with, I think, such good results as to justi- 
fy me in again calling your attention to the subject. The 
difficulties which I then narrated as attending the use of 
electrodes in the pharynx can be much reduced through the 
use of cocaine, and therefore this treatment is practicable for 
almost any person. I believe it is very generally confessed 
that our knowledge of the pathology and pathogenesis of 
the chronic affections of the pharyngeal mucous membrane 
is far from exact or complete. 

Certain well-recognized features or symptoms, such as 
habitual engorgement, hypersecretion, glandular enlarge- 
ment with or without paucity or perversion of secretion, 
constituting the local manifestations of many cases which 
present themselves to us, and which, I am sorry to say, 
puzzle us in the selection of the proper means for ameliora- 
tion. That some of these conditions of the pharynx — 
chronic engorgement, hypersecretion, etc. — are often only 
local expressions of a derangement of the stomach, the in- 
testinal canal, or possibly some more remote organ, is well 
known and does not surprise us, since the anatomical and 
physiological connection or relationship between these or- 
gans and the pharynx is probably intimate. We also meet 
with neuroses of the pharynx — hyperesthesia, spasm, par- 
esthesia, etc. — which are dependent upon derangement 
either of these same organs or the genito-urinary or mental 
apparatus, all of which require little or no local treatment. 
But, besides this class of cases, there are certain organic 
lesions of the pharyngeal mucous membrane which can not 
be traced to any particular disorder of the neighboring or 
remote organs or glands, which are characterized by changes 
such as glandular hypertrophy, general hyperplasia, hyper- 
secretion with or without extraordinary epithelial develop 
ment, atrophy with diminished secretion, etc. It is to these 
that I wish particularly to call your attention. 

They constitute changes which may be regarded as tro 
phic, and which, however inexplicable, must be regarded as 
distinct local disorders. In my mind there has long been a 
conviction that glandular hypertrophy and atrophy with or 
without persistent extra secretion and without much organic 
change in the membrane are due to a perversion of function 
of the nervous apparatus distributed to the pharyngeal re 
gion. It does seem impossible that the mere mechanical 
effect of infiltration or interstitial deposit can account alto 



* Read before the American Laryngological Association, June 24 
1885. 



gether for the wasting of the membrane. Likewise does it 
seem impossible that the disagreeable symptoms of typical 
pharyngeal disease, even when associated with thickening 
or wasting of the glandule, etc., can be fairly attributed to 
ordinary inflammation and its consequences, because we 
often find people with throats presenting such appearances, 
even to a considerable degree, who do not complain of in- 
convenience nor show disturbance of the nutrition of the 
part. Therefore it would seem probable that some of these 
conditions must be at least regarded as distinct local disease 
having for its origin some nutritive abnormality antecedent 
to the inflammatory changes ; and may we not find a possi- 
ble explanation in the supposition of metabolic derange- 
ment through a disordered trophic function of the hypo- 
glossal, pneumogastric, or sympathetic nerves ? 

Considering the analogy between the functions of the 
hypoglossal and the fifth, and the facts already demon- 
strated regarding the trophic influence of the latter nerve, 
this hypothesis would seem to gain support. However, the 
light of further investigation may show that, instead of the 
hypoglossal, either the pneumogastric or sympathetic, or 
both, may be the reigning influence in the nutritive changes 
of the pharyngeal mucous membrane ; but, whichever may 
be the case, the result is the same. Acting upon the fore- 
going theory, I have been led into the employment of dif- 
ferent agents for local use, with a view of counteracting this 
perverted trophic influence ; but, of all the agents used, I 
think I have obtained more lasting effects from galvanism. 
Many of the local stimulant applications, while certainly 
valuable, are soon followed by a reaction which shows the 
excitement to have been only of short duration and in no 
wise of vital character. But with the galvanic current I 
think I have found much more enduring effects ; for example, 
the mucous membrane remains in many cases of a vivid 
color and bathed in a quite fluid secretion for a number of 
hours after the application, and, moreover, leaves a sensation 
of heat and pliability — in cases of atrophy — which the pa- 
tients describe as slightly exhilarating. The effect of the 
application is sometimes felt in adjacent parts — such as the 
cervical region. One of my patients states that the sensa- 
tion of heat always remains in his throat for about forty- 
eight hours. After a few applications the sense of dryness 
and the collection of desiccated secretion in and about the 
naso-pharynx, which occur in the severer forms of chronic 
naso-pharyngeal disease, very sensibly lessen. In cases of 
engorgement accompanied by hypersecretion the result of 
this treatment has been quite efficient. Also in distinctly 
neurotic conditions — such as paresthesia — I have had good 
effects from galvanism. 

I usually pursue the following method, viz. : First wash 
off the surface of the membrane, by means of a spray or 
posterior douche, with a solution of common salt or other 
appropriate fluid ; then apply a four-per-cent. solution of 
cocaine hydrochlorate, and, after an interval of about five 
minutes, apply the electrodes (which 1 here show you), one 
through the nasal passage and the other to the posterior 
and lateral wall of the pharynx, moving them both rapidly 
but gently over the surface, being careful to keep them 



HOOPER: THE RESPIRATORY FUNCTION OF THE HUMAN LARYNX. [N. Y. Med Jo 



2 

closely applied. I generally connect the electrodes with 
two cells (increasing to four or five) of a battery composed 
of the improved Leclanche cells. The electrodes are not 
covered, but naked, unless it is desired — as in cases purely 
nervous — to apply one electrode to the side of the neck, 
when that is covered. Gagging and muscular movements 
require the removal of the instruments, after a few seconds, 
for a short period of repose, when they are reapplied per- 
haps four or five times, according to the tolerance of the 
patient and the sensible effect produced. The seance may 
be repeated two or three times a week, as may seem advis- 
able. I have experienced the greatest difficulty from the 
intolerance of the parts in question to the manipulation, 
but, as before mentioned, the use of cocaine has afforded, in 
the majority of cases, the desired tolerance. However, as 
might be expected, the drug to a certain extent antagonizes 
the effect of the galvanic application, and must be compen- 
sated for either by a longer or more frequent manipulation. 
In some cases one thorough treatment a week will prove 
sufficient. 

Of course, it is not expected that this, any more than 
any other, plan of treatment will restore already destroyed 
tissue, but that it is competent to arrest those metamorpho- 
ses which finally result in either the loss of glandular as 
well as other elements of the membrane, or the substitution 
of adventitious for the normal tissues, I firmly believe, in 
view of my experience with it. The period of time re- 
quired for reaching permanent results will vary, of course, 
according to the kind of case and the state of chronicity 
presented. The only therapeutic theory which I have to 
offer is a very commonplace one, viz., the restoration of the 
nutrition and normal secretion of the parts through the 
direct application of the electric fluid to the terminal nerve- 
filaments. 



THE RESPIRATORY FUNCTION OF TILE 
HUMAN LARYNX* 

FROM EXPERIMENTAL STUDIES IN THE PHYSIOLOGICAL 
LABORATORY OF HARVARD UNIVERSITY. 

By FRANKLIN H. HOOPER, M. D., 

BOSTON. 

The human larynx has two principal functions : (a) The 
respiratory, (b) the phonatory. They are mentioned in the 
order of their importance, for, while the muscles concerned 
in phonation, supplemented by other constrictors, are 
charged with the additional duty of closing the laryngeal 
aperture to protect the air-passages from the entrance of 
foreign bodies, yet it must be conceded that, whether em- 
ployed in phonation — marvelous as this function is — or 
brought into action to exclude some foreign substance, the 
part performed by these constrictors is entirely subordinate 
to that of the respiratory muscle of the larynx, whose office 
is to hold the glottis open in order to insure an uninter- 
rupted passage of air to and from the lungs. f Nevertheless, 

* Read before the American Laryngological Association, June 24, 
1885. 

f The intrinsic laryngeal muscles are in pairs except one, the trans- 
verse arytenoid. The posterior crico-arytenoids are the respiratory 



it is this important muscle which is not only the chief 
among the intrinsic muscles of the larynx, but also one of 
the most essential of the whole body — a muscle, be it re- 
membered, of organic life * — that many writers would have 
us helieve has a special tendency to succumb to disease. 
Gerhardt, in his well-known paper,f was perhaps the first to 
speak of unilateral paralysis of this muscle (the posterior 
crico-arytenoid) as the most innocent of all forms of laryn- 
geal paralyses. He points out that neither the voice nor 
the respiration is impaired in such lesions. Schech J writes 
in the same strain, and believes that, as the voice and quiet 
respiration are not affected in these instances, this circum- 
stance accounts for their having escaped more frequent men- 
tion. Two prominent exponents of this theory (Rosenbach * 
and Semon ||) have stated that in central or peripheral affec- 
tions where the filaments of the recurrent laryngeal nerve are 
compressed, the fibers innervating the respiratory muscle are 
earlier affected than those going to the phonatory muscles ; 
that this is in accordance with the well-ascertained fact that, 
in central or peripheral nerve lesions, the extensor muscles A 
are more readily paralyzed than the flexors; that there is a 
" proclivity of the adductor fibers of the recurrent laryngeal 
nerve to become affected sooner than the adductor fibers, or 
even exclusively, in cases of undoubted central or peripheral 
injury, or disease of the roots or trunks of the pneumogas- 
tric, spinal accessory, or recurrent nerves." Another au- 
thor Q has recently gone so far as to say that the vul- 
nerability of these a&ductor fibers is a fact upon which all 
observers are now agreed. 

We hazard the opinion, notwithstanding, that if we 
investigate this complicated subject from a somewhat differ- 
ent point of view — one not strictly clinical — we may dis- 
cover certain reasons why one should not subscribe uncon- 
ditionally to this conception of the pathology of laryngeal 
neuroses. We propose, therefore, to inquire into the truth 
of this problem purely from an anatomical, physiological, 

muscles. The phonatory muscles, which, like the respiratory muscles, 
are attached to the arytenoid cartilages, are the internal thyroaryte- 
noids, the lateral crico-arytenoids, and the transverse arytenoid. These 
phonatory muscles are, when it is necessary, brought into action solely 
to close the glottis and not for the purpose of phonation. Under these 
circumstances they are supplemented by the muscles which compose 
the aryteno-epiglottidean folds, and which, together with certain other 
muscular fasciculi, may be classed as the sphincter group — the con- 
strictor vestibuli laryngis. The thyro-cricoids are also phonatory mus- 
cles; but with these, on account of their anatomical situation, we have 
nothing to do in this paper. 

* By this expression we refer to the normal automatic character of 
the muscular action, and not to the microscopic structure of the muscle 
itself. 

f " Studien u. Beobachtungen iiber Kehlkopflahmung," Virchow's 
"Archiv," vol. xxvii, p. 88, 1863. 

$ " Experimented Untersuchungen iiber die Funktionen der Ner- 
ven und Muskeln des Kehlkopfes," " Zeitsch. f. Biologie," Band ix, p. 
258, 1873. 

* "Bresl. arztl. Zeitschr.," Nos. 2-3, 1880; "Berlin, klin. Wochen- 
schr.," No. 11, 1884; Virchow's "Archiv," Band 99, 1885. 

I Mackenzie, " Diseases of the Throat and Nose," German edition, 
1880 ; " Arch, of Laryngology," vol. ii, No. 3, 1881 ; " Berlin, klin. 
Wochenschr.," Nos. 46-49, 1883; Ibid., No. 22, 1884. 

A To this assumption that the posterior crico-arytenoid muscles are 
extensors we shall recur. 

() Gottstein, "Die Krankheiten des Kehlkopfes," p. 192, Wien, 1884. 



July 4, 1885.] HOOPER: THE RESPIRATORY FUNCTION OF THE HUMAN LARYNX. 



3 



and experimental standpoint. This being, then, in no sense, 
a clinical paper, clinical evidence will not be offered, al- 
though the writer's experience is far from being in accord 
with the dictum that the nerve filaments which preside over 
the most useful and important function of the larynx should 
be especially prone to have that function arrested. The 
superior laryngeal nerve, and the median laryngeal, recently 
described by Exner,* need not in this study concern us. 
The only other nerve, as far as we know to-day, going to 
the intrinsic muscles of the larynx is the inferior or re- 
current laryngeal. This nerve, according to our present 
knowledge, is purely motor, \ and supplies all the intrinsic 
laryngeal muscles except the longitudinal tensors, the thyro- 
cricoids. It is an anatomical fact that it does not send off 
any branches to these muscles until it has reached the 
border of the cricoid cartilage. In its trunk, therefore, are 
contained two sets of nerve fibers — the respiratory and the 
phonatory — which must necessarily be strictly differentiated, 
since they are destined for muscles which carry on two 
separate and distinct functions. Now, where do these two 
sets of nerve filaments come from ; is their origin as dis- 
tinct as their function ; whence do they derive their sepa- 
rate individualities ; which are relatively or numerically the 
stronger ? 

The sources from which nervous impulses for the larynx 
may be received are the brain, the medulla oblongata, and 
the spinal cord. The channels through which they may be 
transmitted are the several motor nerves which join the 
pneumogastric before the recurrent is given off, for we are 
aware that from this point the recurrent proceeds to the 
larynx without any branch or junction which is in any way 
connected with the functions of that organ. 

The experimental researches of Krause,J and the clinical 
observations of Delavan,* justify the belief that there is a 
center of motion for the larynx in the cortical substance of 
the brain. It is also probable, as advanced by many, that the 
several nerve filaments of the recurrent laryngeal may have 
independent ganglionic centers somewhere in the brain or 
medulla. Let us now follow down the real motor nerve tract 
of the larynx from the medulla oblongata to the point of exit 
of the recurrent laryngeal from the pneumogastric, and enu- 
merate the different nerves which, from what we know posi- 
tively or imagine hypothetically, may in any way influence 
either of the functions of the larynx. In so doing we shall 
adopt Longet's classification,! who divided them into the 
direct and the indirect. Starting, then, at the medulla, we 
name as the direct communications to the pneumogastric the 

* " Die Innervation des Kehlkopfes," " Sitzungsb. d. k. Akademie 
d. Wissenschaften," Band 89, Abth. iii, 1 u. 2 Heft, 1884. 

\ We are aware that some have stated, but without giving experi- 
mental data to substantiate the assertion, that the recurrent contains 
sensory as well as motor fibers. We have not the space here to dwell 
upon our own experiments to determine this point, but they justify our 
remark that the recurrent is "purely motor." 

t " Ueber die Beziehungen der Grosshirnrinde zu Kehlkopf und 
Rachen," " Sitzungsberichte der kgl. preuss. Akad. der Wissensch. zu 
Berlin," November, 1883. 

* " On the Localization of the Cortical Motor Center of the Larynx," 
New York "Med. Record," February 14, 1885. 

| " Traite de physiologie," vol. iii, p. 512, Paris, 1869. 



internal branch of the spinal accessory, the facial, the hypo- 
glossal, and the anterior branches of the first and second cer- 
vical. The sympathetic may also furnish some direct fibers. 
Under the head of indirect nerves — namely, those which join 
the pneumogastric after having previously passed through 
the sympathetic ganglia — we have all the branches of the 
cervical below the second, and those of the dorsal nerves 
situated, of course, above the point where the inferior 
laryngeal shoots off from the pneumogastric to run its back- 
ward course to the laryngeal muscles. 

Our knowledge of the part played by these different 
nerves in the performance of the functions of the larynx is 
now, and, from the inherent difficulties of the problem, must 
for a long time to come remain, unsatisfactory. The mass 
of contradictory statements which one encounters in work- 
ing up a subject in any way connected with the respiration, 
and consequently with the pneumogastric nerve, is a suffi- 
cient admonition against too positive and dogmatic asser- 
tions. We approach this question, therefore, with reserve, 
admitting, as we must, that a great part of the subject is yet 
hardly beyond the confines of plausible conjecture. 

It is pretty certain, however, as determined by the relia- 
ble experiments of Bischoff,* Longet,| CI. Bernard,J and 
Schech (loc. cit.), that the spinal accessory is a purely motor 
nerve presiding over phonation, and having nothing to do 
with the respiratory function of the larynx.* That there 
may be other phonatory fibers in the pneumogastric we can 
not gainsay. Now, how is the respiratory function inner- 
vated ? Probably in many different and complex ways, in 
accordance with the truth of the physiological law enunciated 
by Longet.|| " Les moyens d'innervation propres a entretenir 
le jeu d'un organe se multiplient en raison de son importance 
physiologique." The posterior crico-arytenoids — the respi- 
ratory muscles of the larynx — are paramount to all the rest 
in physiological importance. From many sources they re- 

* " Nervii accessorii Willisii anat. et physio].," Heidelberg, 1832. 

f " Rech. expeVimen. sur les fonctions des mus. et des nerfs du lar- 
ynx," etc., " Gaz. med. de Paris," 1841. 

\ " Fonctions du nerf spinal," etc., " Le?ons sur la physiologie et la 
pathologie du systeme nerveux," tome ii, Paris, 1858. 

* Experimental physiology teaches us that if we cut the recurrent 
nerves of a kitten or a puppy a few days old it immediately dies of 
suffocation, which is not the case in old animals. The reason of this, 
as originally explained by Legallois (" Experiences sur le principe de la 
vie," Paris, 1812), is because in very young animals the cartilaginous 
portion of the glottis is but slightly developed, and, the soft and yield- 
ing parts not being held in position by the muscles, the laryngeal walls 
are sucked together by the inspiratory effort, and the laryngeal aperture 
is accordingly completely closed. CI. Bernard showed that section of 
the spinal accessory in a kitten five weeks old was followed by aphonia, 
but glottic respiration remained free. Two days afterward, the kitten 
having remained well but voiceless, its recurrents were cut, when it in. 
stantly died asphyxiated. He concludes from this that the pneumogas- 
tric has a motor power independent of the spinal accessory which per- 
mits the animal to breathe after the latter has been cut ; or, in other 
words, the larynx is a vocal organ when excited by the spinal accessory, 
and a respiratory organ when under the influence of the pneumogastric, 
or more probably of other motor nerves associated with it. In certain 
animals, as the chimpanzee, the internal branch of the spinal accessory 
does not blend with the pneumogastric, but goes direct as a separate 
nerve to the larynx. 

| "Traite 1 de phys.," vol. iii, p. 517, Paris, 1869. 



4 



HOOPER: THE RESPIRATORY FUNCTION OF THE HUMAN LARYNX. [N. Y. Med. Jock., 



ceive an abundant nerve supply, which is to protect them 
from disease, not to open up new channels by which harm 
might come to them. With others we assume that there 
are independent ganglia in the central nervous system which 
are essentially their own. Being respiratory muscles, it is 
more than probable that they may receive nerve force from 
such respiratory nerves as the facial, the hypoglossal, and 
the others already mentioned which run into the pneumo- 
gastric. But in this connection we must quote Longet's 
own words : * "Si la phonation, fonction secondaire et 
accessoire, depend d'un nerf unique et disparait avec lui, la 
dilatation respiratoire de la glotte, si essentielle, si indispen- 
sable a la conservation du la vie, est sous la dependance ou 
plutot sous la protection de nerfs multiples qui, dans cer- 
tains limites, peuvent se suppleer les uns les autres. Aussi, 
comine je l'ai deja fait remarquer, precisement avant de 
donner origine aux recurrents qui animent les muscles crico- 
arytenoidiens posterieurs, voit-on les pneumogastriques em- 
prunter des fibres motrices a des nerfs qui to us intervien- 
nent dans la respiration." 

Summing up what has preceded, we can say that it all 
points to the conclusion that the respiratory nerve filaments 
contained in the recurrent laryngeal are derived from a 
greater variety of sources than the phonatory. 

We pass now to the experimental evidence bearing on 
this point. It is a fact, familiar to all, that if anything 
other than air finds its way into the larynx it produces, by 
reflex action, a sudden closure of the glottis. It is equally 
certain that, under normal conditions, the same contraction 
of the laryngeal muscles may be instantly called forth by 
direct stimulation of one or both of the recurrent nerves. 
Now, it may with reason be asked, How is it that this con- 
stricting action of the phonatory muscles is brought about 
if it be true that the nerve fibers animating the dilators of 
the glottis are the stronger and the more numerous ? Why 
should we not get adduction of the vocal bands instead of 
adduction on irritating the recurrent nerves ? The phona- 
tory muscles are to the respiratory muscles as five to two, 
and the closure of the glottis has always been ascribed to 
the superior numerical strength of these constrictors. Yet 
if we compare, bulk for bulk, the muscular fibers which 
compose the five muscles of phonation with those of the two 
respiratory muscles, we do not find that they are much, if 
any, in excess of the latter, and we venture to think that 
there is some other factor concerned in this phenomenon 
apart from mere muscular force. It may be sought, per- 
haps, in this important difference between the respiratory 
and the phonatory function of the glottis — namely, that, 
while the respiratory muscles are ever on the alert, holding 
the glottis open during the entire healthy life of an indi- 
vidual, in his waking as well as in his sleeping hours, the 
phonatory muscles, on the other hand, are more dependent 
upon the consciousness of the individual in order to respond 
to any irritation. To explain : The phonatory function of 
the phonatory muscles could, as far as life is concerned, be 
dispensed with. Not so their constricting action with the 
view of excluding the passage of foreign bodies to the lungs. 
The constrictor muscles of the larynx are the sentinels who 

* Loc. cii., p. 518. 



guard the approach to these vital organs. But they cease 
to act if the animal is in profound narcosis ; they are asleep, 
so to speak, on their watch. A man in the condition known 
as " dead drunk," lying, let us suppose, on his back witli his 
mouth open, would offer no obstacle to prevent any living 
insect that chanced his way from crawling in and out of his 
mouth, or meandering round in his larynx a voionte, without 
exciting reflex contraction of its muscles. The power of 
ether, chloroform, and other amesthetics to impair the action 
of these constrictors is too well known to need mention. 
To carry this line of thought a little further, should we not 
expect that, provided we could preserve the organic life of 
an animal while its volition was at the same time completely 
abolished — should we not expect, we ask, under these cir- 
cumstances, to get a dilatation of the glottis on irritating the 
recurrent nerves instead of a closure, for the posterior crico- 
arytenoid muscles are muscles of organic life ? Indeed we 
believe we should, and we submit the following experiments 
in support of that belief. In performing the experiments 
the writer has had the advantage of the collaboration of 
Professor Henry P. Bowditch, to whom he would express 
his thanks. With one exception, when a horse was the sub- 
ject of an experiment, the animals used were dogs, the 
proper selection of which for studies in experimental laryn- 
gology is highly important. If a dog is either very old or 
very large he is most unsatisfactory, if not absolutely worth- 
less. He should be small and young ; the breed is of no 
consequence. By arranging him in the following manner a 
perfect view of the glottis can be obtained : After being 
thoroughly etherized, he is secured on his back to a dog- 
holder. A longitudinal incision is made in the skin cover- 
ing the larynx, the fascia is divided, and the muscles are 
drawn aside. The larynx and trachea are thereby brought 
into view. One or both of the recurrent laryngeal nerves 
may now be exposed. The mouth is held open by the up- 
per jaw being firmly attached to the cross-bar of the dog- 
holder, while a cord, tied round the lower jaw and secured 
to any fixed point, keeps the jaws separated to the extent 
desired. If the animal is placed before a window, the light 
is transmitted through the wall of the trachea, illuminating 
the glottis below, while the ordinary head reflector throws 
the light in through the open mouth from above. The 
tongue may be stretched up over the lower jaw and secured 
to the skin by a thread. The epiglottis may be either tied 
up by a string passed through its tip, or held up by an in- 
strument suitably curved, having a long handle. The ac- 
companying picture, taken from a photograph of a dog in 
readiness for experimentation, may serve to make our de- 
scription somewhat clearer. The animal is here shown 
under conditions by which both recurrents could be stimu- 
lated simultaneously.* 

The phenomenon of an irritation applied to the recur- 
rent laryngeal nerve producing an adduction of the corre- 
sponding vocal band was first observed by accident. A 

* For the sake of completeness of the figure, the primary coil is 
represented as connected with a small bichromate cell, but in practice 
it was connected with a Grove cell in a battery-closet. The induction 
apparatus is the one described and figured in the " Proceedings of the 
American Academy of Arts and Sciences," October 12, 1876. 



July 4, 1885.] HOOPER: THE RESPIRATORY FUNCTION OF THE HUMAN LARYNX. 



5 



small dog, of no particular breed, of an age estimated at 
about ten months, as it still had some of its puppy teeth, 
was being prepared for a different order of research. On 




looking for the left recurrent nerve, it was not found in its 
proper anatomical situation, but two small nerves were dis- 
covered near by. As it was doubtful what these two 
branches were, or whether they went to the larynx at all, a 
shielded electrode was placed on the outer and larger nerve, 
and, while the vocal bands were watched through the mouth, 
it was irritated. The very unexpected result of the stimu- 
lation was a forcible adduction of the left vocal band. Dr. 
J. W. Warren, assistant in physiology, was requested to 
come and witness this unusual sight. The ether sponge had 
been removed from the dog since the beginning of the ex- 
periment, and by the time Dr. Warren was ready to look at 
the larynx the animal was somewhat out of its influence.* 
At all events, on stimulating the nerve a second time, the 
familiar closure of the glottis was manifested instead of the 
dilatation so evident a few moments before. On the assump- 
tion that the degree to which the animal was narcotized 
might have something to do with these phenomena, a large 
quantity of ether was again administered. After the dog 
was profoundly under its influence, the nerve was irritated 
a second time, when both Professor Bowditch and Dr. War- 
ren observed the adduction of the vocal band, which was 
more marked in proportion as the stimulation was more in- 
tense. On removing the anaesthetic the dilatation became 
less and less as the animal regained its consciousness, when 
finally a contraction of the glottis supervened. The dif- 
ferent stages in this experiment were readily followed by 
watching the dog's vocal bands while, at the same time, the 
recurrent nerve was irritated at intervals of a few moments. 
Between extreme dilatation and forcible contraction, under 
these circumstances, there seemed to be a neutral point, so 
to speak, when the stimulation produced merely a vibratory 
movement of the vocal band ; but this was soon succeeded 
by an attempt at contraction, and this in turn passed into a 
frank and decided closure of the glottis as the animal, as 
before mentioned, came out of the effects of the ether. 
Similar results followed stimulation of one or the other of 
the divisions of the left recurrent nerve. These branches, 
as was shown by subsequent dissection, and as you will see 
on the specimen, united into one nerve fifteen millimetres 

* Not in any of these experiments sufficiently to feel pain. 



below the cricoid cartilage, and from this point to the larynx 
it is a single nerve. The effects of irritation applied to the 
right recurrent (which was single) agreed with those on the 
left. Stimulation was effected by means of an 
ordinary induction apparatus,* the intensity vary- 
ing from 1 to 40. In general, however, in this 
and in subsequent investigations on other dogs, 
the intensity used was from 1 to 8, never over 10, 
and generally about 3. The experiment many 
times observed on this animal was repeated, with 
confirmatory results, on eight different dogs. But 
the extent and the force, it must be mentioned, 
with which the vocal bands were aMucted differed 
in different dogs. In five instances the arytenoid 
cartilage was rotated outward so forcibly that the 
vocal band lay flat against the wall of the larynx. 
Moreover, in one case there was a marked adduc- 
tion of the vocal band on the opposite side. In 
other dogs a mixed movement was observed — that is, 
the band approached the median line anteriorly, while 
a simultaneous contraction of the posterior crico-aryte- 
noid muscle took place posteriorly, which left, in the 
respiratory portion of the glottis, a large triangular open- 
ing, the glottic picture resembling an exaggerated form of 
paralysis of the arytaenoidseus transversus muscle. These 
phenomena were observed after the recurrent nerve had 
been cut and its peripheral end stimulated as well as 
when the nerve was intact. Usually when a young dog 
is under ether the vocal bands are seen moving rhythmic- 
ally and regularly with respiration. Occasionally, in this 
condition of profound narcosis, we noticed that, although 
the animal was breathing, the respiratory excursions of the 
vocal bands had entirely ceased, the glottis remaining wide- 
ly dilated. As soon as the respiratory movements had re- 
commenced, irritation of the recurrent nerve was followed 
by the usual adduction of the vocal band, an action we have 
become accustomed to regard as the normal one, provided 
the consciousness of an animal is completely abolished by 
sulphuric ether. The most striking demonstration, how- 
ever, of this dilatation of the glottis is obtained by placing 
an electrode on each of the recurrent nerves and irritating 
the two nerves at the same time. Both arytenoid cartilages 
are now rotated simultaneously outward, the glottis is held 
widely open during the stimulation, and the effect is one 
not soon to be forgotten. Krause f has noticed the differ- 
ence in the mobility of the vocal bands according as the 
animal was more or less narcotized. Just in proportion as 
consciousness was deadened, the adductors became sluggish. 
We have repeatedly observed the same effect when the dog 
was under morphine, chloral, or chloroform, but we failed 
with all these agents to obtain the total abolition of the ac- 
tion of the constrictors, on irritating the recurrent nerves, 

* The electrical apparatus was the same as that used by the writer 
in former experiments, to which the reader is referred for an explana- 
tion of the terms employed. (See " Experimental Researches on the 
Tension of the Vocal Bauds," " Trans, of the Amer. Laryngological As- 
sociation," 1883, p. 121.) 

f " Experimentelle Untersuchungen und Studien iiber Contractures 
der Stimmbandmuskeln," Virchow's " Archiv," Band 98, 1884. 



6 



HOOPER: THE RESPIRATORY FUNCTION OF THE HUMAN LARYNX. [N. Y. Med. Jodb., 



which is so marked when large quantities of ether, which 
can be given with safety, are administered. 

From the enormous development of the respiratory 
laryngeal muscles of the horse we conjectured that their 
contraction might be even more easily called forth than 
that of a dog's. In this we were disappointed in the single 
experiment we have performed on this animal. Chloroform 
was the anaesthetic used. An incision was made in the 
thyro-cricoid membrane, through which the finger was in- 
serted and directed between the vocal bands. On irritating 
the recurrent nerve the finger was tightly squeezed by the 
contracting glottis. It is probable, however, that if ether 
had been employed instead of chloroform, and the horse 
thoroughly saturated with it, we should have felt the glottis 
dilate and not contract. We were indebted to the Harvard 
Veterinary College for this observation, and chloroform, for 
reasons of convenience, is the only anaesthetic used in that 
institution. 

With a view to ascertaining whether certain fibers in 
the recurrent were more vulnerable than others, we under- 
took a series of observations of which the following may be 
taken as the type: The nerve was exposed and a small 
crystal of chromic acid was laid upon it. The electrode 
being placed below this point, the nerve was irritated at in- 
tervals while the chromic acid was working its slow destruc- 
tion. In order to watch the effect upon the vocal band, the 
dog was arranged as in the previous experiments. When 
the animal was thoroughly etherized, the results did not dif- 
fer materially from those already described. Stimulation 
produced adduction of the vocal band. As the destructive 
process of the acid progressed, the vocal band gradually be- 
came completely paralyzed. But, even after the respiratory 
movements of the vocal band had entirely ceased, irritation 
was followed by an outward rotation of the arytenoid carti- 
lage. This was only occasionally seen, and lasted but a mo- 
ment, for, as soon as the conductivity of the nerve was 
completely destroyed, stimulation naturally produced no 
effect. We can only say that under these circumstances we 
were able to produce an adduction of the vocal band as long 
as any action at all was produced. How early or how late 
in the destructive process the arfductor or phonatory fila- 
ments were attacked we know not. Being few in number 
(probably) as compared with the respiratory filaments, and 
as ether, as we have shown, arrests so effectually their ac- 
tion, we can not say here whether there was a " proclivity " 
of either the one set or the other to become affected. We 
simply demonstrated that the adductors held on to the last 
moment, for, as long as a single nerve-fiber of any kind was 
left intact, we got a contraction of the posterior crico-aryte- 
noid muscle. When the destruction of the nerve was com- 
plete, the vocal band stood motionless in the cadaveric posi- 
tion. 

In proceeding now to a new order of experiment, we 
are able to record the endurance of the respiratory filaments 
contained in the recurrent laryngeal nerve, while those des- 
tined to supply the phonatory apparatus were altogether 
unable to respond to stimulation. We took a small, young 
dog, exposed the left recurrent nerve, and carefully passed 
a thread through the middle of it. The two ends of the 



thread were tied together in order to prevent its slipping 
out, but no pressure was exerted on the nerve itself. The 
object of the thread was simply to act as a foreign body. It 
was hoped that inflammation might thereby be excited, and, 
as the respiratory or phonatory fibers were the more readily 
attacked, the effect of an irritation applied to the nerve be- 
low the thread would be followed by certain derangements 
of motion of the vocal band. After the thread had been 
secured in the nerve, the parts were restored as nearly as 
possible to their normal situations, and the incision in the 
neck was sewed up. Inspection of the glottis showed that 
both vocal bands were moving normally with respiration. 
The following day the dog was again etherized and the 
glottis examined. No apparent change had taken place 
in either the appearance or natural mobility of the parts. 
The nerve was not disturbed. Since the thread had been 
introduced in it the nature of the dog had undergone a 
change. From having been a confirmed howler he had be- 
come a model of propriety. This happy improvement in 
his disposition lasted until he was destroyed. The quieting 
effect of a thread in the recurrent nerve has been noticed in 
many dogs subsequently. At the end of a week, the dog 
having been etherized and the glottis inspected on four dif- 
ferent occasions, he was again placed under the anaesthetic 
As soon as a cannula could be placed in the external jugu- 
lar vein chloral was injected into it and the ether re- 
moved. It is important to remember that in the following 
experiments the animal was chloralized and not under 
the influence of ether. A slight but evident change was 
now observable in the vocal band corresponding to the- 
nerve operated upon. Although the arytenoid cartilage of 
this side appeared to move with respiration as naturally as 
did the right cartilage, the anterior portion of the left vocal 
band seemed to have lost its " tone " ; it did not come up 
with the same "snap" on expiration as its fellow. On 
opening the incision in the neck, the nerve was found im- 
bedded in a considerable mass of inflammatory tissue, from 
which it was impossible to separate it. After exposing the 
nerve below this point, it was placed in a shielded electrode. 
Irritation with an intensity varying from 1 to 10 produced 
adduction of the left vocal band, and cessation of its respi- 
ratory movements, the band remaining in the position of 
deep inspiration as long as the stimulation was kept up. 
On ceasing the irritation the respiratory movements went 
on as before. The right vocal band was in no way influ- 
enced when the left recurrent was stimulated with an inten- 
sity not exceeding 10. When, however, a more powerful 
stimulation (15) was employed, the right vocal band was 
brought to the median line (phonatory position), while at 
the same time the left band was pulled outward. W'e have, 
then, here a double effect : adduction of the vocal band on 
the healthy side, and a6duction on the side where some 
alteration had taken place in the nerve fibers ; or, in other 
words, the normal action of constriction of the right side 
was manifested while the left band was a&ducted, owing to 
the degeneration of the phonatory fibers, the respiratory 
filaments remaining unharmed ; and, consequently, the respi- 
ratory muscle alone responded to the stimulation. The 
right vocal band was now paralyzed by section of the right 



July 4, 1885.] HOOPER: THE RESPIRATORY FUNCTION OF THE HUMAN LARYNX. 



7 



pneumogastric, the band coming to a standstill in the cadav- 
eric position, or the position we are accustomed to see in 
cases of " recurrent paralysis'." Stimulation applied to the 
right recurrent resulted in a smart closure of the glottis, 
effected by the right vocal band being brought forcibly 
against its fellow, as well as by the contraction of the ary- 
taenoidasus transversus, which approximated the two aryte- 
noid cartilages. It could not be accurately determined 
whether the anterior portion of the left band contracted or 
not, as even a feeble irritation produced such a rapid and 
complete closure of the laryngeal aperture. If the closure 
of the left vocal band was brought into action, it was very 
slight; it was evident that the closure of the glottis was 
chiefly effected by the contraction of the constrictors on 
the right side, and by the arytaenoidseus transversus muscle. 
The electrode was again changed to the left recurrent below 
the insertion of the thread. Stimulation was followed by 
the same outward rotation of the left arytenoid cartilage as 
was observed in the first experiment. There was also a 
marked movement of the right arytenoid cartilage toward 
its fellow, as if by the contraction of the arytaenoidaeus trans- 
versus muscle. The action of this muscle was prominently 
brought into play in the next experiment, when the periph- 
eral end of the left recurrent was stimulated, after section of 
the nerve below the thread. Both vocal bands were now 
paralyzed and standing in the cadaveric position. All 
avenues to the brain were thereby cut off except through 
the anastomoses of the terminal branches of the recurrent 
with those of the superior laryngeal, and, perhaps, also with 
those from the pharyngeal plexus. Irritation of the periph- 
eral end of the left recurrent produced both a contraction 
of the left posterior crico-arytenoid and transverse arytenoid 
muscles. That is, there was a distinct outward i-otation of 
the vocal process of the left arytenoid cartilage, and an 
approximation of both arytenoid cartilages at the same 
time. 

Positive as were the results of this series of experiments, 
we lay no stress upon them. If they are of any worth, it 
will be by suggesting to others some better method than 
was here employed, for all our attempts to verify the ob- 
servations have failed. Even when the thread had been 
previously soaked in a one-per-cent. solution of chromic 
acid it did not cause any material disturbance when intro- 
duced through the nerve and retained there for many days. 
The only change noticed was that, in some of the dogs, a 
more powerful stimulation was required to produce a con- 
traction of the vocal muscles through the nerve operated 
upon than in the opposite healthy side. 

CONCLUSIONS. 

The principal fact herein demonstrated is, to our mind^ 
the power and the endurance of the posterior crico-arytenoid 
muscles and of the nerves which supply them. We have 
spoken of the theoretical reasons: (1) The physiological 
importance of these muscles; (2) their belonging to organic 
life; (3) their extensive nerve-supply, all of which would 
tend to preserve their functional integrity. Moreover, if it 
be true that there is a "proclivity" of the adductor fibers 
to become diseased, and that unilateral paralysis of the ab- 



ductor muscle is such a common and harmless lesion, should 
we not expect, theoretically, that bilateral paralysis of this 
muscle would occur more frequently ? Yet there can be no 
dispute whatever that bilateral paralysis of the posterior 
crico-arytenoids is a disease as rare as it is grave. 

Now, with regard to these muscles being extensors, and, 
like the extensors in other parts of the body — the forearm, 
for instance — more liable to succumb to disease than the 
flexors, we would ask this simple question : Why should the 
terms " extension " and "flexion" be applied to the rota- 
tion of the arytenoid cartilages ? The principal office of 
the posterior crico-arytenoids is to maintain the respiratory 
patency of the glottis. From the beginning to the end of 
life they are in a state of semi-contraction — holding the 
glottis open. They come, therefore, just as near being 
flexors as extensors ; but, as a matter of fact, they are neither 
the one nor the other in the ordinary acceptation of these 
terms as applied to muscles of the general system. They 
are respiratory muscles carrying on a special function. One 
might as well speak of the movements of the pupil as exten- 
sion and flexion, or compare the diastole of the heart to the 
extension of the forearm, or its systole to the bending of 
the little toes. Muscles are analogous as they discharge 
analogous functions. We recognize no more analogy be- 
tween the posterior crico-arytenoid muscles of the larynx 
and the extensor communis digitorum of the forearm than 
there is between "respiration" and "prehension." If we 
wish to seek muscles that are analogous, let us turn to other 
respiratory muscles and ask how they are affected by dis- 
ease. In diffused, progressive diseases of the nervo-muscu- 
lar system we know that of all muscles, except the heart 
itself, those belonging to the respiratory system arc al- 
ways the last to be attacked, and there is no valid reason 
why the respiratory muscles of the larynx — either one or 
both — should offer an exception to the rule, especially as 
they are the most important of all. 

We propose to investigate this subject from a clinical 
aspect at some future date, when, perhaps, the positions 
which immobile vocal bands assume may be sufficiently ex- 
plained without attributing to a wise and conservative na- 
ture a " proclivity " to attack one of the most vital muscles 
of the human system. 

DISCUSSION. 

J. SoLis-ConEN. — It is a great honor to the American Laryn- 
gological Association to have had this valuable paper read be- 
fore it, and I believe it will be an historical paper. These ex- 
periments will be subjected to criticism, and their verification 
will become a matter of history in the controversy now existing 
in the laryngological world as to the liability of these abductor 
fibers to become diseased sooner than the adductors. The dog- 
matism with which the assertion has been made seems to have 
almost paralyzed laryngologists, for, with t he exception of my- 
self, I hardly know of any one who has ventured a word against 
it. Even last year, when I presented a case opposing the the- 
ory, and showed a picture of the larynx, it was simply in defer- 
ence to myself that not much was said against it. Not a single 
member of the Laryngological Association, even of those living 
in Philadelphia, where the patient was, would accept my invita- 
tion to the members to see the patient for himself, and verify 
the fact that the picture I presented was a correct one. The 



8 



GARLAND: BRONCHIAL BREATHING A SIGN OF PLEURITIC EFFUSION. [N. Y. Mjcd. Jo™., 



only word of commendation I received was from Krause, of 
Berlin, who wrote me a very interesting letter, stating that lie 
believed my observation was correct, but attributed the lesion 
to a different cause. I will recall the case for a moment. A 
man had received a wound in the neck. lie had instantly be- 
come aphonic, and when I saw him, a few months afterward, 
one vocal hand was in extreme abduction. I took it for granted 
that the adductor fibers of the pneumogastric had alone been 
injured. Krause's explanation is this: The injury of the ca 
rotid having been attended with haemorrhage, a clot must have 
occurred around the pneumogastric nerve, producing compres 
sion, which became permanent by the formation of the oica 
trices. I do not know where that patient is now. I have seen 
him several times, and the affected vocal band has remained in 
extreme abduction. 

I have had no experience in such physiological experiments 
as Dr. Hooper has made ; but there is a point he spoke of which 
receives clinical support. That is with reference to the influ 
ence of the facial nerve in sending the respiratory forces to the 
pharyngeal. We all know the effect of cold on the facial nerve 
in restoring suspended respiration. I remember a casein which 
I was called to see a child who had diphtheria following measles. 
There was great dyspnoea, but I declined to perform trache- 
otomy, because the child was under two years of age, and I 
knew that the operation was usually unsuccessful after measles 
Knowing the great effect of cold on the facial nerves, in stimu- 
lating the facial centers, we placed ice cloths all over the lower 
part of the neck and jaw up to the ears. Every time the iced 
cloth was placed around the jaw an inspiration took place, and 
the physician in attendance, Dr. O'Hara, by his own efforts in 
keeping this up, saved the child's life. So many times a minute 
he replaced the cloth. Several pieces of cloth were kept be- 
tween two pieces of ice. As soon as the piece in position 
ceased to produce any effect it was replaced by another. So 
there is a point in which, clinically and physiologically, these 
facts support each other. The phenomenon of stimulating one 
recurrent nerve so that its vocal band passes beyond the me- 
dian line in phonation is, if I remember right, confirmatory of 
some of Krause's experiments. He states that, when he stimu- 
lated one nerve, the vocal band of the opposite side moved also. 
It would touch the other, no matter what position it was in, 
whether it was in the median line, in the cadaveric position, or 
in the inspiratory position. In the case presented by me last 
year, when the man tried to speak, the sound vocal band crossed 
away over beyond the median line, and beyond the ordinary 
position which it occupies in the dead body. 

■ Dr. Harrison Allen said that, in his judgment, the analogy 
between constriction and adduction, and between dilatation and 
abduction, was tenable. At least it was of some value in sug- 
gesting research. Careful clinical study would often take the 
place of experiments, and it could be certainly shown from the 
clinical point of view that adductor muscles and constricting 
muscles were alike in their ability to withstand disease as com- 
pared to the abductors and dilators. The morphologist could 
also assert that the position of a flexed point in a limb resem- 
bled the epiglottis when bent down over the aperture of the 
glottis, as the extension of the limb- joint might be compared to 
the erect position of the epiglottis. In the muscles of the limb 
it was found that the adductors were specialized muscles of the 
flexor group, and the abductors of the extensor group. Perhaps 
it might be well to have distinct terms to express this harmony 
of action between flexion and constriction, but, as part of the 
study of muscle phenomena taken in a comprehensive sense, the 
speaker saw much to show that a close association, if not iden- 
tity, existed. 

Dr. Ingals. — In support of the paper in a clinical way, I ' 



have had a recent experience, similar to the one related by Dr. 
Cohen, excepting as to the origin. A gentleman had a cold, 
over-used the voice during the cold, and in the course of two or 
three days became completely aphonic. I saw him five weeks 
later, and found complete paralysis of the left cord, which was 
fixed in extreme abduction. After two months, there had been 
no special change in the position. In phonation the sound cord 
did not cross over as in Dr. Cohen's case ; it crossed a little be- 
yond the median line, but very little. 

Dr. Delavan desired to unite his congratulations with those 
of Dr. Cohen upon the paper just presented. It was a most wel- 
come and valuable addition to our knowledge of the subject, and 
worthy of the highest praise. Reference had been made in the 
paper to a motor center for the human larynx. Since he had 
first called attention to the existence of such a center several 
important contributions had appeared which tended still further 
to establish the fact ; he hoped that sufficient clinical and patho- 
logical evidence would soon be accumulated to place it beyond a 
doubt. 

Dr. IIoopek. — I have only attempted in this paper to study 
this subject on general physiological and experimental grounds. 
Clinically it seems to me a difficult question and one in which 
there are many sources of error. We are dealing, in the first 
place, with one of the most complicated organs in the body, 
and in using the laryngeal mirror we are looking at things 
in perspective, which are in almost constant motion. It is 
often impossible to say whether a vocal band stands motion- 
less in the median line or a few millimetres off from it. If we 
call every paralyzed vocal band we see a paralysis of the poste- 
rior crico-arytenoid muscle, we can multiply such cases very 
rapidly. Not only is the theory that there is a proclivity of 
the posterior crico-arytenoid fibers to become diseased contrary 
to nature, but the dogmatic manner with which it has by some 
been advanced ought of itself to cause us to doubt its accuracy. 
I should feel sorry to have an association like our own subscribe 
to this notion on the very shallow evidence we have at present. 

I must thank you for the attention you have given my paper. 
What there is in it which you say has interested you is chiefly 
due to the perfect arrangements of the physiological laboratory 
of the Harvard Medical School for pursuing such investigations. 
The professor of physiology, Dr. Bowditch, and others con- 
nected with the department, are always ready with their time 
and advice to aid those who are carrying on any kind of re- 
search, and I shall, therefore, convey your kind expressions of 
interest to the quarter where they really belong. 



BRONCHIAL BREATHING A SIGN OF 
PLEURITIC EFFUSION. 

By G. M. GARLAND, M. D., 

ASSISTANT IN CLINICAL MEDICINE, HARVARD UNIVERSITY. 

The differential lines between pneumonia and pleuritic 
effusion are ordinarily so clearly and closely drawn that a 
mistaken diagnosis between these two diseases would appear 
almost evidence of criminal ignorance. And yet such mis- 
takes are made frequently and by skillful observers. Cases 
present themselves wherein all the physical signs fail of con- 
clusiveness, and even the exploratory needle leaves doubt as 
to the actual state of affairs behind the chest-wall. I wish 
in this article to speak of one group of symptoms which, 
above all others, is misleading in pleurisy, and which has, 
within my own experience, been productive of mistaken 
diagnosis in several instances. 

As ordinarily stated in the text-books, the entrance of j 



July 4, 1885.] GARLAND: BRONCHIAL BREATHING A SIGN OF PLEURITIC EFFUSION. 



9 



Diminution 
or 

Absence of 



fluid into the pleural sac obtunds the signs of an air-con- 
taining chamber. In proportion as the pleural tide rises the 
air-sounds are 'dulled, until the negative list includes: 
Respiratory murmur. 
Vocal fremitus. 
Vocal resonance. 
Whispered resonance. 
Percussion resonance. 
Flexibility of chest-wall. 
Silence reigns over the invaded region. This picture is 
typical and obtains in the majority of cases. Occasionally, 
however, a patient appears with many signs of an effusion, 
but, in place of diminished respiratory symptoms, he exhibits 
bronchial breathing and whispered bronchophony all over the 
dull area. Naturally such symptoms lead one's thoughts 
directly to pneumonia, inasmuch as they are declared to be 
indicative of pulmonary consolidation, and are even speci- 
fied as eliminative of pleural fluid. 

Of late years, however, records of such cases have ap- 
peared in the journals, and Bacelli, of Rome, not only has 
described the symptoms, but has made the occurrence of 
whispered pectoriloquy with an effusion in the chest a dif- 
ferential point between a serous exudation and empyema. 

Now, the question arises how to explain this phenomenon 
of bronchial breathing over a fluid effusioD. Bacelli says 
that an effusion which is homogeneous in character — i. e., 
serous — will take up and transmit the vibrations of the col- 
lapsed lung more readily than a purulent exudation, which 
is heterogeneous in character, and hence the occurrence of 
audible whispers in the former case and their absence in 
the latter. This explanation was eagerly seized by clini- 
cians all over the world, and carefully studied until it was 
found that it could not be supported by facts. Whispered 
pectoriloquy occurs with purulent as well as with serous 
effusions, and thus Bacelli's theory falls to the ground. 

In my own study of these eccentric symptoms I have 
arrived at certain conclusions which I desire to submit to 
the judgment of others. In the first place, I have noticed 
that bronchial breathing and whispered pectoriloquy have 
only occurred with effusions of considerable size. I can not 
lay down any boundaries for the amount of fluid necessary 
to produce them, and I imagine this amount would vary 
with other conditions of the chest-wall and lung. In all the 
cases where I have observed these signs, however, the effu- 
sion has reached at least to the third rib in front, and in 
some instances still higher. Secondly, I can not reconcile 
my mind to the theory that the sounds heard are trans, 
mitted through the fluid. Water does not readily take up 
vibrations from the air. Two stones struck together in the 
water cause powerful vibrations of the same, but struck to- 
gether above the water, the sound is inaudible to a sub- 
merged ear. We know that some heart-murmurs are trans- 
mitted long distances. I have traced such murmurs along 
the spine from the occiput to the sacrum. Now, when a 
murmur is heard in the lumbar region, are we to suppose 
that it has taken the short cut through diaphragm, stomach, 
pancreas, and bowels to our ear? Sound vibrations, like 
electrical waves, travel best along lines of least resistance, 
and such lines for the heart-sounds are found along the 



ribs and spinal column. The same argument holds good 
for the bronchial murmur of pleurisy. As an effusion be- 
gins to form, the breath-sounds fade out. They are not 
adapted to pass through the water, nor are they strong 
enough to overcome other lines of resistance. That bron. 
chial breathing is present may be proved by listening to the 
lung above the effusion, and especially high up between the 
shoulder-blades behind. Two conditions might still bring 
these vibrations to our ear when placed over the fluid. 
Should the murmur become strong enough to push its way 
along the ribs, we should hear it ; or, if the tension of the 
chest-wall should be increased in any way so as to convey 
their vibrations more readily, we should obtain bronchial 
breathing over the fluid. A telephone works satisfactorily 
according to the delicacy with which the tension of the 
tympanum is adjusted to the vibrations of the impinging 
voice. As an effusion of fluid in the pleural cavity in- 
creases in size, its weight puts the chest-wall in a state of 
increased tension. The intercostal spaces are obliterated — 
that is, they are stretched more or less taut. In such a 
condition the vibrations which are thrown against the upper 
and the back parts of the chest are readily transmitted all 
over the surface of the affected side and become audible 
over the dull area. 

Recognizing this fact, therefore, that bronchial breath- 
ing may be conspicuously associated with pleuritic effusion, 
we find that this sign is bereft of differential value. Instead 
of a light to illumine the diagnosis, it becomes a dangerous 
shoal, upon which an opinion may be and often is wrecked. 

I need not relate the instances where this bronchial 
breathing has, within my experience, led observers astray, 
but I will merely refer to one illustrative case : I was called 
in consultation to a young lady, twenty-three years of age, 
who was thought to have pneumonia in the left side. Upon 
examination, I found the signs of a pleuritic effusion, except 
the presence of loud bronchial breathing and whispered 
pectoriloquy, all over the dull area. These signs were so 
marked that they almost shook my interpretation of the 
other signs. The impulse of the heart, however, was pal- 
pable and visible about one inch beyond the right mammil- 
lary line, and the young lady said she had noticed this 
beating herself for several days, but had not mentioned it 
for fear of being laughed at, if she said her heart was way 
over there. I tapped the chest, plunging my needle into the 
region of bronchial breathing, and drew off about five pints 
of serous fluid. Now, the displacement of the heart was the 
key-note to this case, and removed from my mind the 
doubts raised by the auscultatory signs. It is, of course, 
possible that a congenital transposition of the heart, or its 
retention in an abnormal position by adhesions from an old 
pleurisy, may render the diagnosis difficult. Such cases 
have occurred. Usually, however, the associated trans- 
position of other organs or the history of the case will en- 
able one to solve the problem. It should be laid down as 
a maxim that the determination of the apex impulse should 
be obligatory in every examination of the chest, no matter 
what the disease or what the nature of the other signs may 
be. The man who makes this his habit will often find 
occasions to congratulate himself upon escape from error. 



10 



ELLIOT: HERPES TONSURANS MAGULOSUS. 



[N. Y. Med. Joijk., 



HERPES TONSURANS MACULOSUS. 
By GEORGE T. ELLIOT, M. D., 

ATTENDING PHYSICIAN TO THE DEMILT DISPENSARY ; ASSISTANT VISITING 
PHYSICIAN TO THE NEW YORK SKIN AND CANCER HOSPITAL, ETC. 

The name herpes tonsurans maculosus is given to an 
acute eruption disseminated more or less over the entire 
body, and caused by the vegetable parasite, the Trichophyton 
tonsurans. It is comparatively infrequent in its occurrence 
here, and, though it has a common origin with ordinary 
ringworm, yet it differs from this in the manner of its in- 
vasion, the acuteness of its development, the extent of sur- 
face implicated, and in its general course. The individual 
lesions retain, however, the salient characteristics of the 
ordinary form. 

The conditions under which it may occur are the same 
as those favoring the development of ordinary ringworm — 
viz., damp lodgings, clothes, etc. ; immediate infection, etc. 
Its own power of infection, in the earlier stages at least, 
does not seem, however, to be very active, and, in the many 
cases which I have observed, I have not yet been able to 
trace its having been communicated from one person to 
another, though all conditions for such communication were 
present. In fact, one of the patients whose cases are re- 
ported here, was for nearly two weeks in constant contact 
with another lady before the disease was treated, and still 
no infection occurred. The other patient, a boy, slept with 
his mother during the entire time that the disease was 
present, and yet she remained free from it. 

In all probability an outbreak of herpes tonsurans macu- 
losus is due to multiple infection. The spores of the para- 
site, obtaining access to the skin at many points, develop 
rapidly under suitable conditions. The simultaneous out- 
break of many lesions, it may be on one part of the body, 
as an upper or lower extremity, or on various parts widely 
separated from each other, and many other factors, speak 
for this manner of origin. These primary lesions may, 
however, again serve as foci of infection, inasmuch as the 
scales of epidermis, being detached by the movements of 
the body, the friction of the patient's linen, carry the spores 
to other as yet unaffected portions, where the process be- 
gins anew. A succession of outbreaks thus appears until, in 
a short time, the patient is covered with the lesions in all 
stages of development. 

There is no particular localization to the disease, and 
no portion of the body is invulnerable to its attack. The 
backs and flanks are, however, usually more thickly studded 
with the lesions, but they are also found in great numbers 
on the face, neck, chest, abdomen, and extremities. The 
outbreak of the affection may be preceded by malaise, some 
fever, loss of appetite, and symptoms of general disturb- 
ance. In the course of the disease the irritation and con- 
sequent loss of sleep in children may give rise to serious 
anxiety. 

The eruption first appears upon the portion of the body 
affected in the form of small papules about as large as a 
millet-seed, of a pale-red color, which disappear on pressure, 
and are slightly elevated. On those parts where there is 
much perspiration the color of the lesions is a dark red. 



Shortly after the appearance of the papules — it may be 
only a few hours — peripheral growth lias ensued and slight 
exfoliation of the epidermis will be observed in the centers, 
while the edges remain smooth and red. The lesions are 
at first circular, but, as they grow larger, many become oval 
in shape, their long axes lying in the direction of the cleav- 
age lines of the skin. Their development is at first rapid, 
and in the course of a week or ten days they attain the size 
of a twenty-five-cent piece, or even larger. Where the edges 
of two or more of the lesions come together, the portions 
which were in contact disappear and a gyrate form of erup- 
tion remains. As the lesions increase in size their edges 
become more elevated, are of a bright red, and scaly, fading 
gradually away into the surrounding tissue. At times vesi- 
culation is observed. The central portions are more or less 
scaly and in process of involution, but in the larger lesions 
these squamas have ceased forming and the skin may be 
found perfectly normal. As they become older they acquire 
a dirty, light-brown color, and they approach more nearly to 
a typical ringworm. Many of the lesions, however, do not 
follow this course, but abort and disappear a few days after 
their first appearance. The itching of the eruption is not 
very severe, unless, through improper treatment or from other 
causes, a consecutive eczema or dermatitis complicates it. 

If left to itself, the disease runs its course in from two 
to six months. The edges flatten out, the erythematous 
condition disappears, desquamation occurs, and the skin be- 
comes again normal. Slight pigmentation may remain for 
a variable length of time. One spot often remains, especi- 
ally on those parts of the body which are well protected, 
and may serve as a focus for reinfection. If the epidermis 
scales are examined under the microscope, the mycelia and 
conidia of the Trichophyton tonsurans will be found, but 
very sparingly, in the younger lesions. In ordinary ring- 
worm, any small epidermis scale will show large numbers of 
the parasite, but a search for hours through squamae taken 
from young spots of herpes tonsurans maculosus will be 
rewarded by the discovery of only a few spores, and perhaps 
a beginning mycelial formation. As the lesions, however, 
become larger and approach more nearly the type of ordi- 
nary ringworm, the presence of the parasite is easily de- 
monstrable. 

The diagnosis presents no special difficulty to the der- 
matologist, and should not to the practitioner in general, if 
the determining characteristics of ordinary ringworm are 
kept in mind. Only at its first appearance can it be mis- 
taken, but its development is so rapid that ordinary observa- 
tion very soon clears up any existing doubt as to the nature 
of the eruption. Should an eczema complicate the disease, 
the finding of a fresh and uninjured lesion will demonstrate 
the real disease present. 

The histories of the two cases which I desire to report 
are as follows : 

Case I. — Miss states that the eruption from which she 

suffers has existed for two weeks, and that during that time she 
has received no treatment. Two days before I first saw her, on 
December 20th, she consulted Dr. Robert Abbe, who kindly re- 
ferred her to me. She informed me that about six months before 
she had had on the outer surface of the left thigh a circular spot 



July 4, 1885.] BARUCH: THERAPEUTIC SIGNIFICANCE OF TEE CERVICAL FOLLICLES. 



11 



with red elevated edges, the center of which was covered with 
squamae. It itched slightly, but caused no special trouble, and 
finally disappeared, though it received no treatment. The erup- 
tion with which she was afflicted at the time I saw her was 
preceded by some feeling of malaise and general disturbance, 
and showed itself simultaneously on neck, flanks, and thighs, 
under the form of small, erythematous, slightly itchy papules. 
They were rather closely aggregated, and peripheral enlarge- 
ment took place rapidly. At first she paid little attention to 
the eruption, until the continued appearance of fresh lesions 
and the growth of the primary ones suggested to her the advisa- 
bility of consulting a physician. On examination, the following 
condition was found : On the face and neck, and along the margin 
of the hair, on the shoulders, arms, and backs of the hands, the 
entire trunk, the thighs as far as the knees, and on the left heel, 
there was an eruption of papules, circular, oval, and gyrate spots 
of all sizes and in all stages of development. In the axillae and on 
the mons Veneris were likewise a few lesions. All the charac- 
terizing objective symptoms were present, and there was no hesi- 
tation in deciding upon the nature of the affection. The largest 
lesions, situated on the left thigh near the crest of the ilium and 
on the back, were of the size of a twenty-five-cent piece, and 
oval in shape. The itching was not very severe, but still enough 
to cause some discomfort. Some of the scales from the younger 
lesions were examined under the microscope, but beyond a few 
spores nothing was found. An anti- parasitic treatment was im- 
mediately instituted, consisting of salicylic acid dissolved in 
alcohol. Two days later, December 22d, the patient reported 
slight improvement, but many new lesions had appeared on the 
abdomen, mammae, etc. Those on the back and thighs were 
improved. 

December 2I^th. — Improvement was more marked. No new 
spots had appeared, and a decided change could be seen in those 
already present. Some had completely disappeared, while even 
in the larger ones the prominence of the edges and the ery- 
thematous condition had greatly decreased. Treatment was 
continued. 

30th. — The disease was substantially cured. No new lesions 
had appeared since her last visit, the erythematous condition and 
elevation of the edges had disappeared, and there remained only 
here and there some roughness of the skin, though in many places 
where the disease had been present the skin was already nor- 
mal in appearance. Treatment was suspended and an indiffer- 
ent ointment was ordered, to relieve the slight irritation which 
the lotion had produced. 

The patient returned, however, ten days later. There had 
been an outbreak on the inner surface of the thighs, and perhaps 
a dozen new spots had appeared. A few days of the treatment 
brought these to an end, and there has been no new return of 
the disease. 

Case II. — In May, 1884, while I was attending the dermato- 
logical class at the Bellevue Out door Department with Dr. W. 
G. Robinson, a boy of twelve presented himself for treatment, 
complaining of an itchy eruption situated principally on the 
trunk, and to a lesser degree on the extremities and neck, which 
had first appeared one week previously. Any description as to 
its first appearance, or his condition at the time, could not be 
obtained. 

On removing his clothes, an extensive eruption was found 
covering the portions of the body already mentioned, and consist- 
ing of lesions of about the size of a five-cent piece. They were 
rather uniform in size, and to a large extent were undoubtedly 
of the same age. They presented the characteristic objective 
appearances already mentioned as marking an outbreak of 
herpes tonsurans maculosus. They were all of a light-brown 
color, and little erythema was present, but this was evidently 



due to his decided aversion to the laws of cleanliness. Anti- 
parasitic treatment was immediately instituted. 

The patient returned in four days, and it was found that the 
spots had not increased in size, that no new ones had appeared, 
and that the itching had diminished to a great extent. He was 
directed to continue treatment and to return in a week. On 
presenting himself after that time all signs of the disease were 
gone. There was only a slight roughness of the skin remaining. 

As may be seen, these two cases presented substantially 
the same appearances and course. In both the disease was 
comparatively recent, and, though existing in the vicinity 
and on parts covered with hair, had not been communicated 
to the hair follicles and hairs. If this had occurred, the cure 
of the eruption would necessarily have required a greater 
length of time and more special treatment. 

The treatment of this form of disease caused by the 
Trichophyton tonsurans is in substance the same as that used 
in the other forms, only some care should be taken in the 
choice of the anti-parasitic. It should be borne in mind 
that an application limited to the lesions alone or to a cer- 
tain number of them at one time will be useless; it is abso- 
lutely necessary to apply the anti-parasitic remedy to the 
whole body, even upon those portions which appear perfectly 
normal. It is important to check the progress of the disease 
as quickly as possible, and, the longer it is temporized with, 
the greater the difficulty in curing it, and the greater the 
risk that an eczema or a dermatitis may arise to complicate 
it. After the arrest of the affection, and there is a certainty 
of the death of the parasitic spores, the skin should be pro- 
tected by the inunction of some bland salve, and powder 
should be freely used. More or less exfoliation of the epi- 
dermis occurs, and the skin becomes normal in from a week 
to ten days. 

23 East Thirty-first Street. 

THE THERAPEUTIC SIGNIFICANCE OF 
THE CERVICAL FOLLICLES. 

By SIMON BARUCH, M. D., 

GYNECOLOGIST TO THE NORTHEASTERN DISPENSARY, NEW YORK. 

(Concluded from page 720.) 
The subject of uterine catarrh is referred to incidentally 
and not with a view to discuss it here, because I desire to 
point out the different conditions of the glands in disease 
of the cervix. In the latter atrophy is the exception, cystic 
degeneration being followed by it only after a very long ex- 
istence of the process. A different method is indicated in 
cervical catarrh ; the glandular structure must be reached 
by the treatment if we would succeed. The cyst-like dis- 
tension must be removed by laying open the walls of the 
glands. The latter being very numerous, and their walls 
somewhat tough and resisting, the application of remedies 
should be preceded by scarification of the mucous mem- 
brane and submucous glandular structure, and in the more 
obstinate cases, where no cellulitis coexists, the sharp curette 
would answer a good purpose. Whether the catarrh be 
corporeal or cervical, therefore, the glandular structure is 
the secreting structure, and it must be reached by the 
means indicated. The patient is carefully prepared by re- 
ducing any pre-existing cellulitis, and softening infiltration 



12 



BARUCH: THERAPEUTIC SIGNIFICANCE OF TEE CERVICAL FOLLICLES. [N. Y. Mkd. Jo™., 



in the annexa by the usual remedies, rest, hot douches, gly- 
cerin tampons, etc. If the disease is extensive, or the pa- 
tient very nervous, an anaesthetic may be required. While 
the patient lies in Sims's position, the cervix and vagina are 
thoroughly irrigated by an antiseptic solution ; a Wilson's or 
Goodell's dilator, previously rendered aseptic, is introduced 
into the cervical canal for the purpose of dilating it to the 
required caliber. A blunt- pointed bistoury is now made to 
scarify the canal longitudinally and somewhat deeply. If a 
sharp curette be now made to scrape over the surface, it 
will bring away more or less glutinous, glairy fluid from the 
ruptured cystic follicles, and perhaps some debris of the lat- 
ter. A thorough swabbing with tincture of iodine, after 
bleeding has been somewhat checked by pressure, completes 
the operation. A carbolized glycerin tampon of cotton or 
oakum will neutralize the discharge and allay irritation. 
Hot antiseptic douches may afterward be resorted to daily 
and the treatment continued on ordinary principles. By 
adopting the course here mapped out, we follow the teach- 
ings of modern surgery, which are applicable in gynecology 
as well. The method here proposed may appear somewhat 
heroic, but we have a heroic disease to deal with. More- 
over, it is well known that even more radical measures have 
been advocated and practiced for the cure of obstinate cer- 
vical catarrh. Schroeder has recommended very highly, for 
the cure of those obstinate cases in which great glandular 
enlargement of the mucous lining exists, the excision of the 
entire diseased mucosa. He makes a.n incision on each side 
of the cervix, so as to divide it into two separate halves, up 
to the inner os. The mucous membrane and glands are 
dow removed by an incision passing through the cervical 
parenchyma ; each lip is turned upon itself, and its folded 
surfaces are stitched together, so that the entire cervix is 
covered within and without by squamous epithelium. Ols- 
hausen reports eighty cases, and he regards this operation, 
done under continuous antiseptic irrigation, as not only free 
from danger, but remarkable in its results. Hegar, Kehrer, 
and others have devised similar operations. All these sur- 
gical procedures prove the great significance of the cervical 
follicles, for it is evident that the removal of the mucosa 
containing them is regarded as the most essential element 
in the treatment of intractable cases of uterine catarrh. 

The radical cure of so-called hypertrophy of the uterus, 
chronic metritis in the various forms in which the cervix is 
involved and involution has been interrupted, has frequently 
been accomplished hy A. Martin (" Arch, fur Gynaekolo- 
gie," 1879, 488). The failure of all local therapeutics by 
caustics, injections, etc., has placed this malady in the 
category of incurable diseases. Carl Braun had shown in 
1864 that involution was hastened by amputation of the 
cervix, and Martin followed and confirmed Braun's ideas. 
He operated in seventy-two cases, chiefly complicated with 
ectropium, erosions, and ulcers of the portio vaginalis, 
with perfect cure in sixty-four cases; portions 3 to 4 ctm. 
long were removed, and in the course of a few weeks com- 
plete involution resulted. Kehrer and Schroeder, also He- 
gar, cited similar experiences during the discussion, the 
former citing forty to fifty cases in which he obtained good 
results by excision of triangular pieces on each side and 



union of the edges (is this not akin to Emmet's opera- 
tion ?). 

In this country these heroic operations have not received 
much approbation, first, because they mutilate and dis- 
figure the cervix uteri more or less, or, when the latter is 
entirely removed, it becomes difficult to retain the uterus 
in position ; and, second, because we have in Emmet's opera- 
tion a superior procedure in the class of cases referred to by 
Schroeder and Martin, which, occurring in parous women, 
are almost invariably connected with lacerations of the cer- 
vix. There had been no operation devised which removed 
diseased tissues and at the same time restored the cervix to 
an almost normal form and condition after the traumatism 
of childbirth before Dr. Emmet gave to the world his now 
classical operation of trachelorrhaphy. Indeed, to him we 
owe the recognition of the fact that a lacerated cervix com- 
pletely or partially healed, combined with more or less 
cellulitis, is at the bottom of the great preponderance of 
uterine diseases, outside of neoplasms and malpositions. 
But what Dr. Emmet has taught, and is still teaching with 
more emphasis than all else, and what yet is more neglected 
and misunderstood, is the principle that his operation is not 
intended as a plastic procedure for the reunion of the torn 
edges of the cervix, but that its aim and scope lie far beyond 
the mere aesthetic effect, in the removal of diseased tissues, to 
ivhose presence are due the local and especially the reflex 
symptoms which we are called upon to treat. It is remark- 
able how slowly the appreciation of this principle and of 
these facts, which we daily observe here, has dawned upon 
gyna?cologists abroad. It is not so surprising that lacera- 
tions of the cervix were not recognized in England so long 
as they were sought for through the old tubular speculum, 
because only their exposure by Sims's speculum, and the 
approximation of the torn edges by means of tenacula, 
could convince skeptics. In Germany, however, where 
Sims's and Simon's retractors are in constant use, Emmet's 
views have not received that warm appreciation which is 
accorded to them in this country. The reason is obvious to 
any one who is familiar with German gynaecological litera- 
ture, which contains the most garbled descriptions and 
most erroneous views concerning the operation for lacer- 
ated cervix. For instance, Olshauseu says ("Klinische Bei- 
trage zur Gynaek. und Geburtskulfe," 1884, p. 32), in re- 
ferring to Schroeder's operation : " We agree with him 
that, in the so-called laceration-ectropium, it is more safe, 
and at the same time a not more serious procedure, to ex- 
tirpate the diseased mucosa than to make the Emmet 
' ectropium operation.' We have, therefore, not been able 
to become friendly to the latter, and have only executed it 
a few times." Dr. Emmet's operation is really intended to 
" extirpate the diseased mucosa." Hegar tells us (" Hegar 
und Kaltenbach," 1881, p. 539) : "Emmet hopes, by simple 
union of sutures, to relieve the patients of all their troubles 
and to produce a recession of the tissue changes " ; and He- 
gar dismisses the description of the operation for lacerated 
cervix in these words : " While the assistant holds the lips of 
the os uteri on a stretch, the edges of the tear are freshened 
smoothly and thoroughly by knife or scissors ; the fresh- 
ened surfaces are brought together by needles, etc. As the 



July 4, 1885.] BARUCH: THERAPEUTIC SIGNIFICANCE OF THK CERVICAL POLLICLES. 



operation is only slightly painful, chloroform is usually dis- 
pensed with " •(!). 

These brief references from prominent German authors 
afford ample evidence of the fact that the principle as well 
as the technique of Emmet's operation ia not understood. 
Any one who has seen Dr. Emmet operate will smile when 
he reads the description given by Hegar. AVhoever has 
seen Dr. Emmet labor from ten minutes to an hour, or even 
longer, over a lacerated cervix, digging and snipping away 
diseased glands and cicatricial tissue, knows that it is not 
the slight operation described by Hegar, and will appreciate 
how egregiously his work is misrepresented abroad. We 
can not wonder that the imperfect knowledge of this valu- 
able surgical procedure has failed to establish its useful- 
ness. Only a few days ago I heard Dr. Emmet inveigh 
bitterly against the practice of superficial denudation. He 
said that he believed the operation was doing more harm 
than good, because every novice deemed himself competent 
to perforin it without really understanding the essential prin- 
ciple, which was " to remove the cicatricial plug.' 1 '' He also 
said that he never operated for lacerated cervix unless there 
were symptoms indicating the necessity for the procedure. 
While I appreciate fully the fact that the mere existence 
of the laceration of the cervix is not the exciting cause of 
those symptoms which keep the poor woman in a constant 
state of invalidism, I do not believe that the latter are in- 
variably, or even frequently, due to "a cicatricial plug," 
but that at least the catarrh and the erosion, and probably 
also the reflex symptoms, owe their origin to Another factor, 
viz., disease of the glandular structure, which is almost in- 
variably present. In those trying cases of cervical catarrh 
connected with abrasions, hyperplasia of the cervix, and 
subinvolution, which are the fertile source of ill-health in 
parous women, and to detail whose symptoms would be to 
you but an oft-told tale, a lacerated cervix is, as I have said, 
a frequently co-existing condition, and constitutes, together 
with more or less pelvic cellulitis, the chief element in the 
case. That this is a clinical fact is attested by the results of 
the operation of trachelorrhaphy when properly executed, 
viz., when it is done not alone f jr the purpose of restoring 
the tear, but for the 'purpose of extirpating the diseased 
mucosa, with its numerous diseased follicles, down to the 
healthy parenchyma. 

I show you here a specimen of this condition, and 
you will see one of the glands forming a large cyst, which 
I have opened for your inspection. All the pathological 
changes which have been detailed under the general head 
of cervical catarrh, as involving the mucous membrane, 
are here seen in an exaggerated form, owing to the ob- 
struction in the circulation of the cervix, the eversion of 
the lips, and the neighboring cellulitis. Erosions, too, 
present an additional source of pain and discharge. No 
application of caustics will cure these cases, for how can 
we penetrate these callous structures and cyst-walls ? We 
may heal the erosions over by a slow process, squamous 
epithelium taking the place of the cylindrical or the everted 
mucous membrane. We may by this means check the 
secretions from the surfaces within reach of applications, 
among which nitrate of silver has proved the best, but 



Uj 

yet the most harmful eventually, because of the inodular 
tissue produced by it. Crude pyroligneous acid is much 
used by the Germans in erosions. But so long as cystic 
degeneration of the follicles remains, so long as new cysts 
form, our patient will continue to suffer the backaches and 
reflex symptoms which render her life miserable. How 
often women apply for relief under these conditions, and 
how rarely they receive it by medicinal application, is within 
the experience of all. But, if we have regard for the true 
cause of these symptoms, we may afford them relief by simply 
puncturing the glands separately, or, what is better, by deeply 
scarifying the entire everted surface, from the inner os to the 
point beyond'the junction of the vaginal covering of the cer- 
vix, by radiating incisions. The haemorrhage may be a little 
free, but can readily be checked by pressure. The relief from 
distress is marvelous ; and those who have seen these poor 
women return again and again with the request for the same 
treatment will not be skeptical regarding my proposition, 
that in these diseased and distended glands lies the true cause 
of the trouble. Indeed, such cases may, by scarification, hot 
douches, glycerin tampons, and rest, be almost entirely 
restored, unless the latter important element can not be 
gained, as is the case in women who have household or 
other duties to perform. In the latter, as also in the more 
pronounced and intractable forms among the better circum- 
stanced, nothing short of trachelorrhaphy will bring perma- 
nent relief. But the operation should be thorough ; all dis- 
eased and hyperplastic structure should be removed, and 
the cervix should be restored as nearly as possible to its 
normal size and shape. Unfortunately, there are specialists 
even who do not in this respect follow the principles laid 
down by Dr. Emmet, and who, as he says, inclose the "cica- 
tricial plug," whose removal he regards as paramount, in 
the newly made wound. Among gynaecologists in this city 
even I have seen few who succeed in giving the cervix 
after this operation an almost virginal shape, as Dr. Em- 
met almost invariably does, by first slitting up the angle 
for the removal of cicatricial tissue, and then bringing 
the edges together by deep sutures directed toward the 
angle of the wound and not across from one edge to the 
other. I am disposed to believe that it is not this re- 
moval of the "cicatricial plug " which renders Dr. Emmet's 
operation in his own hands so signally successful, but that 
the solution lies in the complete ablation of the diseased 
gland structure which necessarily follows the removal of 
this cicatricial plug. When a considerable wedge is excised 
from the angles of the laceration, the surgeon is compelled 
to resort to free ablation of the thickened flaps, in order to 
bring them into nice apposition, if he would avoid inclosing 
a deep gap in the angle ; the result is a cervix almost vir- 
ginal in appearance, which I have seen very few surgeons 
besides Dr. Emmet able to produce. Let it be borne in 
mind that the great aim of the operation of lacerated cer- 
vix is the removal of the diseased gland structure ; let this 
be unsparingly removed, and this great health-saving and, I 
believe, life-saving operation will perform its proper func- 
tion. 

There is no treatment for subinvolution which can com- 
pare to trachelorrhaphy in brilliancy of results. When we 



14 BARUCH: THERAPEUTIC SIGNIFICANCE 

read the description of this disease, which is now known to 
be almost invariably only a portion of a complexus of con- 
ditions following an imperfect "getting up " from childbed ; 
and if we compare the results of treatment by ergot, tonics, 
baths, astringents, electricity, and injections, which was in 
vogue several years ago, with the brilliant results of trache- 
lorrhaphy — we find cause to congratulate ourselves on the 
fact that we live in this happy era in which surgery counts 
its triumphs daily. 

A few weeks after the wound is healed the uterine canal 
shows a decrease of depth, there is new life infused into its 
circulation, involution is re-established, and with it the pa- 
tient is restored to health. How many weary years have 
been passed in bootless medication, how many days and 
months of invalidism have been suffered ere this happy 
consummation was reached by one brilliant stroke of the 
surgeon's hand, the sufferer often tells with a sorrowing yet 
with a grateful heart. 

Some twelve years ago I wrote an elaborate article on sub- 
involution for the Charleston, S. C, " Medical Journal," in 
which I presented all the remedies which were at that time 
thought efficient. The recollection of my lengthy account 
of the therapeutics of this affection has led me to these re- 
flections upon the comparative advantages of the present 
method of treating subinvolution. 

In those cases of cervical disease termed ulceration and 
erosion the follicles are again found to enact an important 
pathological role. Whether they become more freely de- 
veloped on their original site, as maintained by Fischel, or 
whether a new formation of follicles ensues, as is, with more 
convincing proof, asserted by C. Ruge, the fact is established 
beyond contradiction that so-called erosions of the portio 
vaginalis rest upon a groundwork of glands. " The entire 
eroded spot," says Ruge, "is the free surface of a new de- 
velopment of glandular structure! upon the normally gland- 
less portio vaginalis; it is covered with a cylindrical epithe- 
lium in single layer. At the same time are formed numer- 
ous depressions into the tissue, which in single spots are 
still solid, but soon become hollow, and present themselves 
as glandular tubes or bags, which, penetrating deeply 
into the tissue, branch freely and communicate often with 
neighboring glands. From the latter arise partly con- 
stricted rounded formations whose inner walls are covered 
with very fine papillary projections. Repeatedly we found 
a complete spongy system of glands. The larger glands lie 
in the mucosa, but even muscular fibers do not hinder their 
further development. In many cases they reach such mas- 
sive accumulation that all normal structure is pressed aside. 
All these constrictions and depressions have cylindrical epi- 
thelium which resembles the more superficial. The inter- 
vening structure is a young connective tissue permeated by 
numerous capillary loops. In a peculiar manner we found 
repeatedly real gland lamina as well as follicle-like forma- 
tions on parts where the portio vaginalis was covered super- 
ficially by normal epithelium and where the papilla? even 
showed no change. Their origin is very probably due to the 
small crypts which in the cervical canal are covered with cylin- 
drical epithelium [italics mine], but which are sparse in the 
portio, by means of the deep penetration of these crypts in a 



OF THE CERVICAL FOLLICLES. fN. Y. Med. Jodb., 

direction from within outward toward the portio, whose epi- 
thelium they push before them. It is possible that they may 
partly arise in the connective tissue of the portio vaginalis." 
From this description of the pathology of erosions it would 
appear that the follicular structures form their basis, and that 
it would be irrational to attempt to cure these surface 
breaches without destruction of the gland-tissue. Strong 
acids answer a good purpose here, because the diseased sur- 
face is within easy reach and may be again and again sub- 
jected to treatment. 

But the more radical removal by the sharp curette or 
spoon, or by scissors and knife, as is best done by Emmet's 
or Schroeder's operation, leads to a more rapid and successful 
issue, and affords a permanent result, because the glands, 
which are the chief pathological factors, are thoroughly re- 
moved. I have no experience with Schroeder's operation, 
but Emmet's trachelorrhaphy, or some modification of it, 
has served an excellent purpose in such cases. 

The radical extirpation of the gland-tissue becomes more 
imperative if we accept the view of Huge and Veit, that there 
is not only a close relationship between erosions and cancer, 
but that many cases of cancer may actually be traced to an 
origin in the gland structure. The process of repair in these 
erosions confirms this view. 

" While in the repair of erosions, in some cases, the 
cylindrical epithelium transforms itself into squamous epi- 
thelium, which, by increase and layering, gradually narrows 
the gland-outlets more and more, compresses them, as it 
were cuts them off, so that they persist under the squamous 
epithelium ; on the other hand, instead of this incomplete 
healing, the squamous epithelium may creep into the glands. 
Often the upper half of the gland is found already filled. 
But another process of termination may occur. Frequently 
everything up to a small piece of gland-tissue, correspond- 
ing to its bottom, may be converted into squamous epithe- 
lium or into a better-layered, polymorphous, dermoidal epi- 
thelium. In short, we obtain in these processes of cure 
pictures such as we have frequently described in the devel- 
opment of cancer, as beginning of the latter. A gland in 
process of cancerous degeneration is not to be distinguished 
from one in process of cure. In the cervix an analogous 
process of cure takes place when an erosion becomes covered 
by epidermis ; the squamous epithelium which forms in sim- 
ple ectropium, or in prolapsus with ectropium, often creeps 
into the gland only on one side in order to fill it gradually n 
("Zeitschr. fiir Geburtsh. und Gynaek.," 1881, p. 174). The 
pathological study of cervical diseases which are here pre- 
sented briefly points to the inevitable conclusion that the 
cervical follicles are significant factors in all benign diseases 
of the cervix uteri. 

The connection between benign and malignant disease 
of the cervix has already been referred to. It remains now 
to show more definitely how far the cervical follicles are sig- 
nificant as elements in the pathology of that most loathsome 
of all titer ine diseases, carcinoma. I must again draw from 
that valuable source of information on pathology, the labors- 
of Ruge and Veit, who have examined numerous specimens 
of carcinomatous tissue, removed, in various stages, by Carl 
Schroeder and others. The minute descriptions of the mi- 



July 4, 1885.J BARUCH: THERAPEUTIC SIGNIFICANCE OF THE CERVICAL FOLLICLES. 



15 



croscopic appearances, which are beautifully illustrated in 
their work ("Der Krebs der Gebarmutter," "Zeitsch. fur 
Geburtshiilfe unci Gyna3kol," 1881), establish beyond a doubt 
the correctness of their view that carcinoma of the cervix origi- 
nates in the follicles. " When it develops within the cer- 
vix, it arises from the connective tissue or the already pres- 
ent though rankly growing glands, while, when it develops 
on the portio vaginalis, it takes its origin in the connective 
tissue or in newly formed glands. Hence both forms have 
this much in common, although they differ in some other 
respects : that a glandular formation serves them as their 
point of origin " (pp. 208, 209). 

It would probably interest you as deeply as it interested 
me during the investigation of this momentous question to 
follow these practical microscopists, who are intimately con- 
nected in their work with Berlin's best clinical gynaecolo- 
gists, in the description of some of the microscopic draw- 
ings which they furnish. But I will quote very briefly, in 
order to impress upon your minds the salient points in con- 
nection with my subject, only the concluding summary (p. 
169) : " First, the squamous epithelium was found sometimes 
slightly thickened near the end (of the portio) ; next fol- 
lowed glandular erosions, covered with cylindrical epithe- 
lium which degenerated into cancer. In many cases in 
which cancer apparently occurred upon the plain termina- 
tions of the squamous epithelium, its development from 
glands could frequently be demonstrated beyond a doubt. 
We can say that a large proportion of carcinoma of the 
portio vaginalis are gland cancers, which receive their origin 
in newly developed glands (erosions). We therefore still 
remain upon our former standpoint, that erosions are not 
always simple and insignificant processes. We are glad (in 
reply to Scanzoni, who said that the incipient stages of de- 
velopment of cancer were unknown) to say that we have seen 
early development of cancer, and that we have demonstrated 
for this category a development from glands." 

What lessons are inculcated by the pathological evi- 
dences which I have brought before you to prove the para- 
mount influence of the gland structure as a factor in benign 
as well as in malignant diseases of the cervix uteri ? The 
original intention of my studies on the subject was to 
demonstrate the urgent necessity of recognizing the gland 
structure in the operation for lacerated cervix, to show how 
important the mere repair of the laceration would be in the 
direction of a cure, and to insist upon the necessity of free 
thorough, and unsparing removal of all gland-tissue in this 
operation. But, as the subject became more and more 
elaborated in my mind, I was led into the more complete 
review which is here presented. 

Ruge and Veit have told us : " A gland in process of 
cancerous degeneration is not to be distinguished from one in 
process of cure.'" Pregnant words these from the pen of 
careful observers, reminding us how readily the scale may 
be turned from a benign to a malignant process. 

The microscope has confirmed the conclusions which 
clinical observation has furnished. Dr. Emmet has long 
insisted that epithelioma of the cervix was almost invari- 
ably connected with a previously existing laceration, having 
never discovered epithelioma in women who had not at 



some time been delivered of a fcetus. Breisky, Gusserow, 
Hofmaier, and others have confirmed Emmet's view to this 
extent at least, that, in their experience, carcinoma of the 
cervix is comparatively rare in nullipar.ius women. 

The lesson, therefore, is plain. Lacerations, erosions, 
and ulcerations, which do not readily respond to ordinary 
treatment, must be regarded with suspicion as possible 
sources for the development of malignant disease. When 
surgical measures are demanded for their repair, the removal 
of the gland structure is paramount, and should be executed, 
as vigorously as is done in true malignant disease, by en- 
croaching as far as possible upon the healthy parenchyma 
of the cervix. . This complete extirpation of the gland 
structure will not only secure a complete cure in benign 
cases, but prevent the possible development of malignant 
disease. 

Summary. 

1. A thorough knowledge of the anatomy, physiology, 
and pathology of the cervical follicles will simplify the 
treatment of many uterine affections. 

2. The cervix uteri represents a large gland of active and 
important function in the various sexual relations of woman. 

3. In the majority of the more common diseases of the 
uterus the mucous membrane and its follicles play the most 
important role. A recognition of this fact will make treat- 
ment more successful. 

4. Metritis, subinvolution, hyperplasia with catarrh, ero- 
sions, etc., must be studied in connection with the glands 
of the cervix. 

5. In obstinate cases medicinal applications fail because 
the secreting surfaces of the follicles are not reached. 
Scarification and the curette are valuable adjuncts in nulli- 
parous women or in parous women without cervix lacera- 
tion. 

6. In parous women with lacerations, trachelorrhaphy is 
the most valuable procedure. As a simple plastic operation 
it will fail. Success depends on extirpation of the follicles, 
which is more important than " removal of the cicatricial 
plug." 

7. The microscope demonstrates the dependence of ca- 
tarrh, ulceration, erosion, and hypertrophy of the cervix, and 
often also of the body of the uterus, upon the glandular 
structure of the cervix uteri. 

8. The cervical follicles are significant as elements in 
the pathology of cervix cancer, because the microscope 
demonstrates the dependence of the latter upon erosions, 
which are based upon the gland structure. 

9. Laceration and erosion must be regarded with sus- 
picion, as possible sources of future malignant disease. In 
operating for their removal, extirpation of the cervical folli- 
cles must be unsparing. 

Protective Choleraic Inoculation in Spain, under the direction of 
Dr. Ferran, the Government prohibition of which has been withdraws, 
is to be further prosecuted, as we learn by the " Union medicate, " un- 
der the observation of a French commission consisting of Professor 
Brouardel, M. Roux, who is an assistant of Pasteur's, and M. Albarran, 
the last-named gentleman having been chosen on account of his knowl- 
edge of the Spanish language. 

The Honorary Degree of LL. D. has been conferred on Dr. Thomas 
F. Rochester, of Buffalo. 



16 



BOOK NOTICES. 



[N. Y. Use. Joi k., 



^ooh flotites. 



Lectures on Diseases of the Nervous Sytsem, especially in Women. 
By S. Weir Mitchell, M. D., Member of the National Acad- 
emy of Sciencs, Physician to the Orthopaedic Hospital and 
Infirmary for Diseases of the Nervous System, etc. Second 
Edition, revised and enlarged, with Five Plates. Philadel- 
phia : Lea Brothers & Co., 1885. Pp. 287. [Price, $1.75.] 

Dr. Mitchell's numerous admirers will welcome a new edi- 
tion of hi? interesting little volume, especially as it contains 
several fresh pages on the subject of hysteria, on which he 
always writes so graphically. Chapter XVI, on "The Rectum 
and Defecation in Hysteria," contains a number of curious and 
interesting facts concerning this protean disorder. The closing 
chapter contains a concise statement of the advantages and 
method of application of the rest-cure, which the talented au- 
thor has already rendered so famous. 

The subject of chorea is carefully treated of, the relation of 
the disease to locality and meteorological conditions heing care- 
fully studied and illustrated by charts. The style is, like that 
of all of the author's writings, clear and forcible. Aside from 
its scientific value, the book offers most interesting reading. 



Modern Therapeutics of the Diseases of Children, with Observa- 
tions on the Hygiene of Infancy. By Joseph F. Edwards, 
M. D., Editor of the "Annals of Hygiene," etc. Philadel- 
phia: D. G-. Brinton, 1885. Pp. vii-17 to 346, inclusive. 

The author modestly remarks in the preface that "no simi- 
lar work of anything like this extent has ever been published," 
a statement calculated to raise the expectations of the reader to 
a high pitch. Unfortunately, these expectations are not en- 
tirely realized. The volume certainly contains a number of 
valuable suggestions, and will be acceptable to a certain class of 
readers, but, to tell the truth, there is so much waste matter in 
it that the true pearls are hard to find. Numbers of the pre- 
scriptions which are credited to certain modern physicians have 
been in use for over a century, and many of the " eminent spe- 
cialists " whose teachings are quoted are unknown to fame. 

The main criticism to be urged against the book is its pro- 
lixity. The writer has certainly devoted an immense amount 
of time to the compilation. 

The Year-Boole of Treatment for 1881f. A Critical Review for 
Practitioners of Medicine and Surgery. Philadelphia : Lea 
Brothers & Co., 1885. Pp. 316. 

This little volume contains a large amount of useful infor- 
mation within a small space. The names of the contributors 
are a sufficient guarantee of the accuracy of the work. The 
paragraphs, although necessarily condensed, are sufficiently full ; 
the references to current literature are carefully given, and 
show wide research. Although the writers are English, they 
generously allow a fair amount of space to extracts from Ameri- 
can journals. We note, as especially worthy of commendation, 
the sections on " Diseases of the Stomach, Intestines, and Liver," 
by Dr. Brunton ; on "General Surgery," by Mr. Bryant; and 
on "Diseases of Women," by Dr. Williams. Mr. Champneys 
contributes a lengthy chapter on "Midwifery," and Mr. Mal- 
colm Morris an excellent resume of the latest advances in the 
department of dermatology. There are two carefully prepared 
indexes, one referring to the authors quoted, the other to dis- 
eases. The book is of a size suitable for the pocket, and the 
type and binding leave nothing to be desired. 



Modern Medical Therapeutics: A Compendium of Recent For- 
mulas and Specific Therapeutical Directions, from the Prac- 
tice of Eminent Contemporary Physicians, American and 
Foreign. By George H. Napheys, A. M., M. D., etc. 
Edited by Joseph F. Edwards, M. D., and D. G. Brinton, 
M. D. Eighth Edition, Enlarged and Revised. Philadel- 
phia: D. G. Brinton, 1885. Pp. xv-629. 
The fact that this work has reached an eighth edition proves 
that it must be popular with the profession, yet this is not 
necessarily an argument in favor of its intrinsic excellence. 
Although we do not regard with much favor the regular prac- 
tice of borrowing other men's prescriptions, there are undoubt- 
edly useful hints to be derived from a study of the methods of 
treatment employed by different practitioners. The advantage 
complacently set forth by the editors, that the present edition 
has been increased by "more than a hundred pages," will not 
strike the thoughtful reader as especially great. There is too 
much irrelevant matter in the book already. The size of the 
volume is the least of its attractions. While, as we before re- 
marked, we do not become enthusiastic over Dr. Napheys's 
works, they certainly possess good points, and should not be 
dismissed without some commendation. 

BOOKS AND PAMPHLETS RECEIVED. 

On Some Common Injuries to Limbs; their Treatment and 
After-treatment, including Bone-setting (so called). By Ed- 
ward Cotterell, M. R. C. S. Eng., L. R. C. P. Lor.d., etc. With 
Illustrations. London: H. K. Lewis, 1885. Pp. x-108. 

Hay Fever, and its Successful Treatment by Superficial Or- 
ganic Alteration of the Nasal Mucous Membrane. By Charles 
E. Sajous, M. D., etc. Illustrated with Thirteen Wood Engrav- 
ings. Philadelphia : F. A. Davis, Att'y, 1885. Pp. 103. 

A Treatise on Practical Chemistry and Qualitative Inorganic 
Analysis, adapted for Use in the Laboratories of Colleges and 
Schools. By Frank Clowes, D. Sc. Lond., etc. With Illustra- 
tions. From the Fourth English Edition. Philadelphia: Lea 
Brothers & Co., 1885. Pp. xiv-376. 

The Ten Laws of Health ; or, How Diseases are produced 
and prevented: and Family Guide to Protection against Epi- 
demic Diseases and Other Dangerous Infections. By J. R. 
Black, M. D. Philadelphia: J. B. Lippincott Co., 1885. Pp. 
xviii-13 to 413, inclusive. [Price, $2.] 

The Pathology and Treatment of Stricture of the Urethra 
and Urinary Fistulas. By Sir nenry Thompson, F. R. C. S., M. B. 
Lond., etc. Fourth Edition. Philadelphia : P. Blakiston, Son 
& Co., 1885. Pp. xii-254. [Price, $2.] 

Medical Topics. Containing: 1. Hints aDd Suggestions for 
Reform in Medical Education. 2. A Plea for the State Regula- 
tion of Medicine and Surgery. 3. Medical Education ; its Ob- 
jects and Requirements. By F. R. Sturgis, M. D., Ex-president 
of the Medical Society of the County of New York, etc. New 
York: William Wood & Co., 1885. Pp. 63. [Price, 25c] 

Pneumonia in Young Children. By L. Emmett Holt, A. M., 
M. D., Attending Physician to the Children's Department of the 
Northwestern Dispensary, etc. [Reprinted from the " Medical 
Record."] 

Epilepsy. By L. W. Baker, M. D., Superintendent of a Hos- 
pital for Epileptic Children, Baldwinsville, Mass. [Reprinted 
from the " Journal of Nervous and Mental Disease."] 

Catalogo espanol, clasificado, descriptive) e ilustrado, de los 
libros publicados por D. Appleton y Ca. 1885. 

Second Annual Report of the New Y"ork Skin and Cancer 
Hospital. 

Minutes of the Medical Society of Delaware, at its Ninety- 
fifth Annual Session. 



July 4, 1885.] 



L KADI SO 



ARTICLES. 



17 



THE 

NEW YORK. MEDICAL JOURNAL, 

A Weekly Review of Medicine. 

Published by Edited by 

D Appleton & Co Frank P. Kosteb, M. D. 

NEW YORK, SATURDAY, JULY 4, 1885. 



THE INTERNATIONAL MEDICAL CONGRESS. 

In this issue we conclude our report of the Chicago meet- 
ing of the American Medical Association's Committee on the 
International Medical Congress. Several of the members of 
the Original committee were present and took part in the pro- 
ceedings, a fact that can not be otherwise construed than as a 
complete recognition on their part — and presumably on the 
part of the original committee as a body — of the new commit- 
tee's legitimacy. 

The enlarged committee, therefore, with power to fill vacan- 
cies occurring even among the original members, now consti- 
tutes the only body charged with the organization of the Con- 
gress. That being the case, its acts assume an importance that 
might have been questioned before. We are glad to be able to 
say that the convictions which we expressed two weeks ago 
have been justified by the moderation and breadth of view 
shown at Chicago. Of course, we deplore the fact that the 
committee was under compulsion to cut off the heads of a num- 
ber of distinguished men whose co-operation the Congress can 
ill afford to spare ; and it is humiliating to reflect that this com- 
pulsion was not the outgrowth of any spontaneous expression 
of feeling on the part of the profession, but merely the natural 
sequence of the excitement brought about at New Orleans. It 
was none the less real and morally binding, however, and we 
readily concede that the committee, whatever may have been 
the feelings of its individual members, had no course open to it 
hut the very course that it took. When in the future — and, 
to judge by the action taken in Philadelphia, in the near future 
— it comes to be admitted on all hands that an honest difference 
of opinion as to how far a sentiment should be allowed to sway 
the policy of the profession ought never to have been magni- 
fied into an issue before which every other consideration should 
he made to yield, and perverted into a test of personal worth, 
it will certainly be recognized that the responsibility for carry- 
ing out those monstrous notions to the extent of wantonly 
humiliating some of the best men to be found in the ranks of 
the medical profession, and at the same time detracting from 
the strength of the home representation at a convocation of the 
medical men of the whole world, condemnation will not be 
visited upon this committee, but upon those whose acts called 
it into existence. 

The committee, we repeat, is not to be held chargeable with 
the crippling of the Congress that must be the result of the 
foolish policy settled upon at New Orleans— a policy that has 
already begun to bear its bitter fruit, as shown by the action of 
our brethren in Philadelphia. The preambles and resolution 
adopted by them (for a copy of which we are indebted to the 



courtesy of the "Medical News," of Philadelphia) show plainly 
that the strong men of the profession in that city are not to be 
made the cat's paws of a little knot of agitators. It is signifi- 
cant that several of the names signed to the resolution are those 
of men appointed to high positions in the new list of officers of 
the Congress. 

There was only one other main question with which the 
committee had to wrestle, and that was the demand for a more 
strictly geographical representation in the organization of the 
Congress. So far as the proceedings at New Orleans could be 
taken as an indication of what was wanted, this demand seemed 
much more obtrusive than the feeling on the code question. 
There was danger, consequently, that the committee would feel 
constrained to take sweeping measures, and to make the officers 
of the Congress represent not the medical achievements of the 
country, but its territorial districts. We think an examination 
of the new list of officers decided upon by the committee will 
show that, while it has done all that could fairly be expected of 
it by the most exacting stickler for local representation, it has 
yet contrived to fill the prominent places with well-known men 
— men in every way fitted for the positions to which they have 
been appointed. We must therefore congratulate the commit- 
tee upon this portion of its work, and we feel convinced that 
whatever sense of disappointment may be the portion of those 
whose names have been lopped off from the original list will 
arise from the thought, not that they as individuals have had 
an indignity put upon them, but that they are debarred from 
showing their devotion to American medicine on an occasion 
when, more than on any other, it would have been conspicuous 
and effective. While we praise the work of the committee, we 
must confess that the outlook for the Congress is gloomy. 



THE EMBRYOLOGICAL RELATIONS OF CONGENITAL MAL- 
FORMATIONS OF THE PHARYNX. 

At the fourteenth congress of the German Gesellschaft fur 
Chirurgie, an excellent digest of the proceedings of which is 
published in the form of a supplement to the " Centralblatt fur 
Chirurgie," Dr. Albrecht, of Brussels, read a notable paper on 
the morphological significance of pharyngeal diverticula. He 
sought to establish that, besides the lungs, there were two dif- 
ferent sorts of these diverticula in the human subject, namely, 
the dorsal, epipharyngeal, or retropharyngeal, and the lateral 
or parapharyngeal. The epipharyngeal diverticula of man, he 
says, are those which Zenker and von Zietnssen have character- 
ized as ''impulse-diverticiila" (Pulsiotwdwertilcel). In all the 
cases thus far observed the opening of the larynx, that of the 
oesophagus, and that of the diverticulum have all been situated 
at the same level. Since a like diverticulum, the so-called oeso- 
phageal oiecum of the veterinarians, is found as a normal struct- 
ure in several of the Mammalia (constantly in the hog, the 
camel, and the elephant, and occasionally in the ox), Albrecht 
maintains that Zenker and von Ziemssen'a impulse-diverticula 
in man have the morphological significance of atavistic forma- 
tions, and are to be referred to the same sources as the oeso- 
phageal Cfficnm, which latter, furthermore, he looks upon as a 



18 



MINOR PARAGRAPHS. 



[N. Y. Med. Jodh., 



houiologiie of the air-bladder of fishes, having no homology 
with lungs, since there are certain Teleosteans {Diodon, Triodon, 
and Tetrodon) that have both lungs and air-bladders, while, on 
the other hand, in some of the Selachians (Galeus, Mustelus, 
and Acanthias) the air-bladder is found to have the form of an 
epipharyngeal diverticulum. Since in the hog, the oesophageal 
cascum (Raehentasche) of which was demonstrated with a prep- 
aration, the pouch is overlain by the crico-pharyngeus muscle, 
and its mucous membrane can be inverted beneath the crico- 
pharyngeus with the finger, thus what is known in man as 
pharyngocele being produced artificially, we have an explana- 
tion of the presence, often recorded in literature, of muscular 
fibers on the cranial portion of the impulse-diverticulum in 
man, doubted by Zenker and von Ziemssen on theoretical 
grounds. The Zenker-von Ziemssen versus Kouig controversy 
in regard to these muscular fibers is therefore decided in 
Konig's favor, for the cranial portion of the pouch must, under 
all circumstances, be covered by the crico-pharyngeus. 

In man, the author continues, all the parapharyngeal diver- 
ticula have the same morphological significance ; they all origi- 
nate in the second post-oral cleft (bounded by the hyal arch, 
consisting of the styloid process, the stylo-hyoid ligament, and 
the lesser cornu of the hyoid bone, and the ventral rudiment of 
the first branchial arch, the greater cornu of the hyoid bone), 
the cutaneous opening of which is closed, while the blind termi- 
nation thus formed is dilated into a pouch. To the same mode 
of origin we must refer congenital cervical fistulas, and con- 
genital hydroceles, atheromas, and dermoid cysts of the neck. 
If the second post-oral cleft does not close at all, a congenital 
cervical fistula is the result ; if its cutaneous opening closes, an 
internal incomplete fistula is formed, which, if its lateral blind 
end bulges, gives the impression, as in a case cited from Wat- 
son, of a lateral diverticulum of the pharynx ; if both the cuta- 
neous and the pharyngeal openings close, either a hydrocele, an 
atheroma, or a dermoid cyst is developed, according as the con- 
tents are serous, pultaceous, or containing dermoid formations, 
such as hair and teeth. 

Like congenita] fistulas of the neck, the parapharyngeal di- 
verticula lie mediad of the sterno-cleido-mastoid muscle, making 
their way first between the external and the internal carotid 
arteries, then between the glossopharyngeal nerve and the 
stylo pharyngeus muscle, to open finally into the pharynx be- 
hind the pharyngo-palatine arch. The reason why the cutane- 
ous orifice of a congenital cervical fistula and the blind end of a 
pharyngeal diverticulum lie close above the sterno-clavicular 
joint is to be found in the cranio-caudad migration of the two 
respectively, a migration which tallies with the caudad migra- 
tion of the stomach, the heart, and the aortic arch ; and the 
single explanation lies in the fact that, instead of the twenty- 
first spinal nerve, a cranial nerve goes to the stomach in man, 
and the inferior laryngeal nerve makes a turn two feet long, in 
the adult, around the fourth aortic arch (the arch of the aorta 
on the left, and the innominate artery and the proximal portion 
of the subclavian on the right side) before reaching the laryn- 
geal muscles to which it is distributed. The author considers 



that the larynx, the air-passages, and the lungs constitute a 
normal hypopharyngeal diverticulum. 



NEWS ITEMS, ETC. 

Infectious Diseases in New York.— We are indebted to 
the Sanitary Bureau of the Health- Department for the following 
statement of cases and deaths reported during the two weeks 
ending June 30, 1885 : 





Week ending June 23. 


Week ending J Line 3"- 


DISEASES. 












Cases. 


Deaths. 


Caees. 


Deaths. 




7 


1 


13 


4 




54 


7 


29 


1 


Cerebrospinal meningitis . . . 


2 


2 


1 


1 




89 


17 


100 


25 




57 


23 


63 


3"5 



The American Medical Association's Committee on the 
International Medical Congress. — Chicago, June 25th. — The 
meeting of to-day was called to order by the Chairman, Dr. 
Cole, at 9.20 a. m. The minutes of yesterday's meeting were 
read and adopted. Dr. R. Battey offered the following pre- 
amble and resolution : 

Whereas, It is expedient that the meetings of this committee 
shall represent, as far as practicable, the profession of all por- 
tions of our country, 

Resolved, That any member of the committee who may be 
unable to attend a meeting shall be empowered to send as his 
proxy for the meeting any member of the American Medical 
Association in good professional standing, and a resident of his 
State or member of his Government Department. Adopted 
unanimously. 

Chairman Scott, of the sub-committee appointed yesterday, 
stated that the secretary would read this committee's report 
before its adoption, as it had been placed in his hands. Some 
general remarks were made as to the method of adopting the 
rules, and it was decided to act on them seriatim. The result 
of this action was that most of the rules reported by the com- 
mittee were adopted, some amendments being made to a few of 
them. As they can not be given with exactness until after the 
committee's final revision, it is thought best not to attempt to 
incorporate them in this report. It is sufficient to say at pres- 
ent that Rule I was so amended as to guard against the partici- 
pation of irregular practitioners in the meetings of the Con- 
gress. 

That portion of the committee's report which had reference 
to the list of officers for the Congress contained the following 
nominations: For president, Austin Flint, of New York. For 
vice-presidents, N. S. Davis, of Chicago; H. F. Campbell, of 
Augusta, Ga. ; R. P. Howard, of Montreal. Canada ; T. G. 
Richardson, of New Orleans; A. Stille, of Philadelphia; W. 0. 
Baldwin, of Montgomery, Ala. ; H. M. Skillman, of Lexington, 
Ky. ; L. A. Sayre, of New York; W. W. Dawson, of Cincin- 
nati; J. M. Toner, of Washington; W. Brodie, of Detroit; J. 
L. Atlee, of Lancaster, Pa. ; and O. W. Holmes, of Boston. 
For secretary-general, John Packard, of Philadelphia. For 
chairman of the Finance Committee, F. S. Dennis, of New 
Y T ork. For members of the Committee of Arrangements (those 
whose names are printed in italics being also members of the 
executive sub-committee) : 

George A. Ketchum, Mobile; D. A. Linthicum, Helena, 
Ark. ; R. B. Cole (chairman), San Francisco ; Charles Deni- 
son, Denver, Col.: W. C. Wile, Sandy Hook, Conn.; W. E. 
Duncan, Dakota Territory; L. P. Bush, Wilmington, Del.; A. 
Y. P. Garnett, Washington ; R. D. Murray, Moultrie, Pa. ; 
Robert Battey, Rome, Ga. ; E. P. Cook, Mendota, 111. ; F. W. 



July 4, 1885.J 



MINOR PARAGRAPHS. 



19 



Beard, Vincennes, Ind.; W. Watson, Dubuque, Iowa; D. W. 
Stonnont, Topeka, Kan.; W. H. Wathen, Louisville; J. W. 
Dupree, Baton Rtmge; S. 0. Gordon, Portland, Me. ; S. Lynch 
(vice-chairman), Baltimore ; A. H. Wilson, South Boston, Mass. ; 
A. R. Smart, Hudson, Mich.; George F. French, Minneapolis; 
J. M. Taylor, Corinth, Miss. ; N. F. Essig, Plattsburg, Mo. ; 
R. C. Moore, Omaha; J. W. Parsons, Portsmouth, N. H. ; 
William Pierson, Orange, N. J. ; Ellsworth Eliot, New' York ; 
X. C. Scott, Cleveland ; E. P. Fraser, Portland, Oregon ; J. V. 
Shoemaker (secretary), Philadelphia; W. E. Anthony, Provi- 
dence; R. A. Kinloch, Charleston; F. L. Sim, Memphis; J. W. 
McLaughlin, Austin ; E. T. Upham, West Randolph, Vt. ; W. 
C. Dabney, Charlottesville, Va. ; G. Baird, Wheeling, W. Va. ; 
Nicholas Senn, Milwaukee ; J. J. McAchran, Laramie City, Wyo- 
ming Territory; J. B. Hamilton, Washington; Robert Murray, 
TJ. S. Army, Washington ; F. M. Gunnel!, U. S. Navy, Washing- 
ton ; W. Pierson; J. S. Billings, U. S. Army; J. M. Brown, 
U. S. Navy; I. M. Hays, Philadelphia; H. F. Campbell, Au- 
gusta, Ga. ; C. Johnston, Baltimore ; J. W. S. Gouley, New 
York; L. A. Say re, New York; G. J. Engelmann, St. Louis; 
F. S. Dennis, New York ; and J. Packard, Philadelphia. For 
Local Committee of Arrangements : A. Y. P. Garnett (chair- 
man), J. S. Billings, S. O. Ritchie, and Frank Baker, all of 
Washington, with power to add to their number any of the 
physicians of Washington in good standing. For officers of 
sections: Section I {Medical Education, Legislation, and Regis- 
tration). — President, S. E. Chaille, New Orleans. Vice-presi- 
dents: G. Capples, San Antonio, Tex.; R. J. Dunglison, Phila- 
delphia. Secretaries: E. F. Dunbar, Boston; Trail. Green, 
Easton, Pa. Council : H. D. Didama, Syracuse, N. Y. ; D. C. 
Gilman, Baltimore; J. F. Harrison, University of Virginia ; C. 
A. Lindsley, New Haven ; W. Pepper, Philadelphia ; J. F. Prio- 
leau, Charleston ; L. McL. Tiffany, Baltimore ; II. Gibbons, San 
Francisco ; J. A. Dibbrell, Jr., Little Rock, Ark. ; C. L. Allen, 
Rutland, Vt. ; H. O. Hitchcock, Kalamazoo, Mich. ; R. H. Reed, 
Mansfield, 0. ; J. W. Bailey, Gainesville, Ga. ; K. Wylie, San- 
ford, Fla. Section II {Anatomy). — President, J. Leidy, Phila- 
delphia. Vice-presidents: W. Pancoast, Philadelphia; C. W. 
Kelley, Louisville ; S. Logan, New Orleans. Secretaries: W. W. 
Keen, Philadelphia; G. E. de Schweinitz, Philadelphia. Council : 
H. Allen. Philadelphia ; F. Baker, Washington ; A. Henson, 
Philadelphia; T. Dwight, Boston; F. L. Parker, Charleston; 
C. T. Parkes, Chicago; T. T. Sabine, New York; N. Senn, 
Milwaukee ; J. F. Shepherd, Montreal ; R. W. Shufeldt, U. S. 
Army; G. Halley, Kansas City; S. W. Craft, Jackson, Miss. 
Section III {Physiology). — President: J. C. Dalton, New York. 
Vice-presidents: H. P. Bowditch, Boston ; J. F. Hibberd, Rich- 
mond, Ind.: H. N. Martin, Baltimore; M. Michel, Charleston. 
Secretary : J. G. Curtis, New York. Council : G. Baumgarten, 
St. Louis; H. G. Beyer, U. S. Navy ; A. Flint, Jr., New York; 
W. Lee, Washington; J. J. Mason, Newport, R. I. ; II. Sewall, 
Ann Arbor, Mich.; W. F. Hyer, Holly Springs, Mich.; J. H. 
Wyeth, San Francisco; A. D. Brubaker, Philadelphia ; A. F. 
Whelan, Hillsdale, Mich.; T. S. Latimer, Baltimore; S. Putnam, 
Montpelier, Vt. ; C. H. A. Kleinschmidt, Washington. Section 
IV {Pathology). — President: F. Delafield, New York. Vice- 
president: W. Pepper, Philadelphia. Secretaries: H. M. Briggs, 
New York; W. II. Welch, Baltimore; I. N. Himes, Cleveland. 
Council: C. Fenger, Chicago; R. H. Fitz, Boston; E. G. Jane- 
way, New York ; J.B.Johnson, St. Louis; G. M. Sternberg, 
H. S. Army; W. F. Whitney, Boston ; C. H. Hunter, Minneapo- 
lis; E. O. Shakespeare, Philadelphia; II. Schmidt, New Orleans; 
M. Longstretb, Philadelphia. Section V {Medicine — including 
the original section in Nervous Diseases and Psychiatry. — Presi- 
dent: J. M. DaCosta, Philadelphia. Vice-presidents: vVlonzo 
Clark, New York; J. B. McCaw, Richmond; C. F. Folsom, 



Boston ; J. P. Gray, Utica, N. Y. ; J. S. Jewell, Chicago ; 
R. McSherry, Baltimore; A. B. Palmer, Ann Arbor, Mich.; T. 

F. Rochester, Buffalo; S. W. Mitchell, Philadelphia; P. G. 
Robinson, St. Paul. Secretaries : W. Osier, Philadelphia : J. 
T. Whittaker, Cincinnati ; W. Hay, Chicago. Council : R. Bar- 
tholow, Philadelphia ; F. T. Miles, Baltimore ; S. G. Webber, 
Boston ; J. P. Logan, Atlanta ; F. B. Lester, Kansas City ; A. 
B. Arnold, Baltimore ; E. D. Ferguson, Troy, N. Y. ; S. C. 
Chew, Baltimore ; W. H. Geddings, Aiken, S. C. ; W. W. John- 
ston, Washington; G. A. Ketclium, Mobile; F. Minot, Boston; 
B. Robinson, New York ; J. Burnett, Cleveland ; W. W. Cleav- 
er, Lebanon, Ky. ; W. H. Phillips, Canton, O. ; S. S. Clark, St. 
Albans, Vt. ; G. Williamson, Ottawa, Canada ; J. Draper, Brat- 
tleboro, Vt. ; E. Grissom, Raleigh, N. C. ; P. Brice, Tuscaloosa, 
Ala. Section VI {Surgery). — President: D. W. Yandell, Louis- 
ville. Vice-presidents: D. H. Agnew, Philadelphia; W. T. 
Briggs, Nashville ; S. W. Gross, Philadelphia ; W. H. Hingston, 
Montreal ; R. A. Kinloch, Charleston ; E. M. Moore, Roches- 
ter ; M. Gunn, Chicago. Secretaries : J. C. Warren, Boston ; 
I). P. Allen, Cleveland. Council : J. Ashhurst, Jr., Phila- 
delphia; D. W. Cheever, Boston; P. S. Conner, Cincinnati; 

G. E. Fenwick, Montreal ; F. II. Gerrish, Portland, Me. ; 
J. C. Hutchison, Brooklyn ; C. Johnston, Baltimore ; T. M. 
Markoe, New York; A. P. Smith, Baltimore; J. F. Thompson, 
Washington; T. R. Varick, Jersey City ; H. H. Mudd, St. Louis ; 

J. R. Weist, Richmond, Ind. ; J. P. Wall, Tampa, Fla. ; 

Mercer, Omaha ; H. Bingham, Burlington, Vt. ; T. A. Dunsmore, 
Minneapolis; J. T. Carpenter, Pottsville, Pa.; W. S. Janney, 
Philadelphia; J. Garretson, Philadelphia; I. N. Quimby, Jersey 

City; T. A. McGraw, Detroit; Russell, , Wis.; J. H. 

Rawson, Burlington, la.; H. W. Austin, TJ. S. Marine-Hospital 
Service; O. Coskery, Baltimore; W. T. Andrews, Mitchell, 
Dak. ; H. H. Smith, Philadelphia ; Westmoreland, Scran- 

ton, Pa. Section VII {Obstetrics and Gynaecology). — President: 
R. Battey, Rome, Ga. Vice-presidents: W. T. Howard, Balti- 
more; R. B. Maury, Memphis; J. C. Reeve, Dayton, O. ; A. II. 
Smith, Philadelphia ; T. A. Reamy, Cincinnati ; T. G. Thomas, 
New York; W. H, Byford, Chicago; H. P. C. Wilson, Balti- 
more; J. Goodman, Louisville; W. P. King, Sedalia, Mo. Sec- 
retaries: T. Opie, Baltimore; J. R. Chad wick, Boston; G.J. 
Engelmann, St. Louis. Council: R. P. Harris, Philadelphia; A. 
F. A. King, Washington ; E. Van de Warker, Syracuse; W. T. 
Lusk, New York; R. S. Sutton, Pittsburgh; T. Parvin, Phila- 
delphia; R. Glisan, Portland, Oregon; J. Scott, San Francisco. 
0. V. Northam, Lawrence, Kansas ; E. P. Sale, Aberdeen, 
Miss.; W. Varian, Titusville, Pa.; T. B. Harvey, Indianapolis; 
E. Warner, Worcester, Mass.; L. Fay, Lowell, Mass.; D. 
Crea, Council Bluffs, Iowa; B. E. Hadra, San Antonio, Tex. ; 
L. Robinson, San Francisco ; E. S. Dunster, Ann Arbor, Mich. ; 

H. O. Marcy, Boston; T. Opie, Baltimore; W. H. Baker, 
Boston; W. Gardner, Montreal; W. Goodell, Philadelphia; 
A. R. Jackson, Chicago; J. T. Johnson, Washington. Section 
VIII {Ophthalmology). — President: E. Williams, Cincinnati. 
Vice-presidents: II. D. Noyes, New York; E. L. Holmes, Chi- 
cago; W.Thomson, Philadelphia. Secretary: S. M. Burnett, 
Washington. Council: C. S. Bull, New York; A. W. Calhoun, 
Atlanta; H. Derby, Boston; E. G. Loring, New York; W. F. 
Norris, Philadelphia; W. W. Seely, Cincinnati; S. Theobald, 
Baltimore; 0. F. Wadsworth, Boston; II. W. Williams, Bos- 
ton ; J. Green, St. Louis; P. I). Keyser, Philadelphia; D. Hunt, 
Boston ; B. J. Jeffries, Boston ; A. G. Sinclair, Memphis ; B. 
Baldwin, Montgomery, Ala.; W. II. Sanders, Mobile; B. E. 
Frier, Kansas City ; E. Smith, Detroit ; J. L. Thompson, In- 
dianapolis. Section IX {Otology). — President: C. J. Blake, 
Boston. Vice-presidents: A. M. Wilder, San Francisco; II. N. 
Spencer, St. Louis ; D. S. Reynolds, Louisville. Secretary : S. 



20 



MINOR PA 



RAORA PUS. 



[N. Y. Med. Joiik., 



O. Ritchie, Washington. Council: J. II. White, Richmond; J. 
O.Green, Boston; G. Strawbridge, Philadelphia.; S.J.Jones, 
Chicago; C. Turnbull, Philadelphia; J. A. Lippincott, Pitts- 
burgh; C. II. Burnett, Philadelphia; C. J. Lundy, Detroit; E. 
II. Ilazen, Davenport, Iowa. Section X (Dermatology and 
Syphilis). — President: W. A. I lard a way, St. Louis. Vice- 
presidents: J. M. Keller, Hot Springs, Ark.; J. N. Hyde, Chi- 
cago; J. C. White, Boston; L. A. Dubiin^r, Philadelphia. 
Secretaries: F. E. Daniel, Austin, Tex.; W. T. Carlett, Cleve- 
land. Council: I. E. Atkinson, Baltimore; A. R. Roliinson, 
New York; E. Wigglesworth, Boston ; H. C. Yarrow, Wash- 
ington; II. 0, Walker, Detroit; W. F. Glenn, Nashville; H. R. 
Carter, U. S. Marine-Hospital Service ; J. J. McAchran, Lara- 
mie City, W. T. ; J. A. Octerlony, Louisville; LeG. B. Dens- 
low, St. Paul. Section XI (Laryngology). — President: J. N. 
Mackenzie, Baltimore. Vice-presidents: M. F. Coomes, Louis- 
ville : F. I. Knight, Boston. Secretaries : D. Bryson Delavan, 
New York; E. F. Ingals, Chicago. Council: W. II. Daly, 
Pittsburgh; G. W. Major, Montreal; E. C. Morgan, Washing- 
ton; W. Porter, St. Louis; E. L. Shurly, Detroit; R. P. Lin- 
coln, New York; C. Sajous, Philadelphia; H. Goldthwaite, 
New York. Section XII (Public and International Hygiene). 
— President: H. A. Johnson, Chicago. Vice-presidents: A. L. 
Carroll, Albany; J. L. Cabell, University of Virginia; J. B. 
Lindsley, Nashville; J. E. Reeves, Wheeling; J. N. McCormick, 
Bowling Green, Ky. Secretaries: W. Wyman, U. S. Marine- 
Hospital Service; G. H. Rohe, Baltimore. Council: A. Gihon, 
U. S. Navy ; H. B. Baker, Lansing, Mich. ; G. P. Conn, Con- 
cord, N. H. ; W. H. Ford, Philadelphia; H. Leffmann, Phila- 
delphia; D. W. Hand, St. Paul; J. H. Kidder, Washington; J. 
H. Rauch, Springfield, III.; J. H. Raymond, Brooklyn; J. R. 
Smith, U. S. Army; S. Smith, New York; H. P. Wolcott, 
Cambridge, Mass. ; G. B. Thornton, Memphis ; R. M. Swer- 
ingen, Austin, Tex. ; C. M. Hewitt, Red Wing, Minn. ; II. F. 
Lester, Detroit; E. S. Elder, Indianapolis; O. C. DeWolff, 
Chicago; E. L. B. Godfrey, Camden, N. J.; H. S. Orme, 
Los Angeles, Cal. ; J. Holt, New Orleans; W. S. Robinson, 
Musratine, Iowa; W. L. Schenck, Osage City, Kansas; B. Lee, 
Philadelphia. Section XIII (Collective Investigation, Nomen- 
clature, Vital Statistics, and Climatology). — President: N. S. 
Davis, Chicago. Vice-presidents: J. Cochran, Mobile; E. M. 
Snow, Providence. Secretary : J. F. Todd, Chicago. Council: 
N. Allen, Lowell, Mass.; R. A. Cleeman, Philadelphia; J. H. 
Hollister, Chicago; J. T. Reeve, Appleton, Wis.; J. Tyson, 
Philadelphia ; E. T. Sabal, Jacksonville, Fla. ; A. C. Hamlin, 
Bangor, Me. ; T. S. Hopkins, Thomasville. Ga. ; T. J. Allen, 
Shreveport, La. ; C. Denison, Denver ;' H. C. Ghent, Austin, 
Tex. ; E. P. Hurd, Newburyport, Mass. ; E. W. Morley, Cleve- 
land ; O. W. Wight, Detroit; T. T. Miner, Seattle, Wash. T. ; 
P. C. Remondino, San Diego, Cal. ; J. W. Parsons, Portsmouth, 
N. H. ; W. P. Hart, Washington, Ark. Section XIV (Military 
and Naval Surgery and Medicine). — President: D. L. Hunting- 
ton, U. S. Army. Vice-presidents: F. H. Hamilton, New York; 
H. McGuire, Richmond ; S. P. Moore, Richmond ; W. E. Tay- 
lor, U. S. Navy (retired) ; P. O. Hooper, Little Rock, Ark. ; E. 
Andrews, Chicago; E. H. Gregory, St. Louis; D. McLane, De- 
troit. Secretaries : B. F. Pope, U. S. Army ; McF. C. Gaston, 
Atlanta. Council: D. Bloodgood, U.S. Navy; R. B. Bonte- 
cou, Troy, N. Y. ; J. H. Brinton,. Philadelphia; E. J. Marsh. 
Paterson, N. J.; C. M. Mastin, Mobile; G Peck, U. S. Navy; 
W. F. Peck, Davenport, Iowa; C. Smart, U. S. Army; J. R. 
Tryon, U. S. Navy; A. A. Woodhull, U. S. Army; J. W. Ham- 
ilton, Columbus, O.; W. Murphy, St. Paul; W. C. B. Fifield, 
Boston ; E. Goodman, U. S. Army ; W. S. Tremaine, U. S. Army ; 
J. II. Peabody, Omaha; S. T.Armstrong, U.S. Marine-Hospital 
Service. Section XV (Practical and Experimental Therapeu- 



tics). — President: II. C. Wood, Philadelphia. Vice-presidents: E. 
R. Squibb, Brooklyn ; R. T. Edes, Boston ; F. P. Porcher, Churl. - 
ton. Secretaries: R. T. Reichert, Philadelphia; R. M.Smith, 
Philadelphia. Council : G. Griswold, New York; R. Amory, Bos- 
ton ; II. M.Lyman, Chicago; S. Nickels. Cincinnati: F. Steyart, 
Cincinnati ; I. Ott, Easton, Pa. ; D. W. Prentiss, Washington ; C. 
Rice, New York ; C. II. White, U. S. Navy ; T. F. Wood,Wihiiing- 
ton, N.C.; J. M. Flint, U. S. Navy; E. P. Fraser, Portland, 
Oregon; T. F. Breck, Springfield, Mass.; R. D. Webb, Living- 
ston, Ala.; F. Woodbury, Philadelphia; J. V. Van Velsas, 

Yankton, Dakota T. ; Codlock, Knoxville, Tenn. ; J. F. Y. 

Payne, Galveston, Tex. ; T. Weed, Cleveland; D. W. C. Wade, 
Holley, Mich.; R. C. Moore, Omaha; G. M. Garland, Boston; 
Crompton, Lancaster, Pa. Section XVI (Diseases of Chil- 
dren). — President: J. L. Smith, New York. Vice-presidents: 
D. Miller, Chicago; S. C. Busey, Washington. Secretary: E. 
T. Williams, Boston. Council: F. Forchheimer, Cincinnati; J. 
M. Keating, Philadelphia ; W. Lee, Baltimore; J. H. Pope, 
Marshall, Tex.; W. B. Atkinson, Philadelphia; A. Walker, 
Evansville, Ind. ; W. A. Conklin, Dayton, O. ; W. F. Holt, Ma- 
con, Ga. ; K. Johnson, Grand Rapids, Mich. ; C. A. Leale, New 
York; S. II. Charlton, Seymour, Ind.; W. II. Dougherty, Au- 
gusta, Ga. ; B. II. Riggs, Selma, Ala. ; H. H. Middlekamp, Iron- 
ton, Mo. ; J. A. Hodge, Henderson, Ky. ; G. W. Moody, Huron, 
Dakota T. ; A. A. Horner, Helena, Ark. 

Dr. W. II. Wathen offered the following preamble and reso- 
lution : . 

Whereas, It has become necessary, in order that this com- 
mittee may fully understand the professional and personal 
standing of the various persons suggested for appointment, 
therefore be it 

Resolved, That it is the sense of this meeting that all remarks 
bearing upon the qualifications of said persons be considered as 
strictly confidential between the members of the committee, 
and that the report of such remarks, if heretofore recorded, be 
expunged from the minutes. Carried unanimously. 

The committee then adjourned, to meet in St. Louis on the 
Monday preceding the next meeting of the American Medical 
Association. 

New York State Medical Association, Northern Branch. 

— The first annual meeting will be held in Utica on Tuesday, the 
7th instant. The following papers are expected to be read : 
"Well-water and its Uses," by Dr. Malek A. Southworth, Little 
Falls ; " The Treatment of Haemorrhoids by Recent Methods 
and Instruments," by Dr. Leroy J. Brooks, Norwich ; " Extra- 
uterine Pregnancy," by Dr. William A. Hall, Fulton; "Anky- 
losis of the Knee Joint as a Remedy for Extreme Paralysis of 
the Leg, due to Infantile Paralysis," by Dr. Stephen Smith, New 
York; "The Advantages of Paris as a Place of Medical Educa- 
tion," by Dr. M. M. Bagg, Utica; " Jaborandi and its Uses in 
TypLoid Fever," by Dr. Wallace Clarke, Utica. 

The District Medical Society for the County of Hudson, 

N. J., will meet at the Stevens Institute, in Hoboken, on Tues- 
day, the 7th inst., at 3 o'clock p. m. Dr. W. P. Watson will 
read a paper on Cholera Infantum, and Dr. J. Lewis Smith and 
Dr. J. H. Ripley, of New York, are expected to take part in 
the discussion. 

The International Medical Congress and the Medical 
Profession of Philadelphia. — A meeting of the members of the 
medical profession of Philadelphia concerned in the organiza- 
tion of the International Medical Congress of 1887 was held at 
the Hall of the College of Physicians, on Monday, June 29th, 
Dr. Alfred Stille in the Chair. Dr. David W. Yandell, of Louis- 
ville, was present by invitation. 



July 4, 1885.1 



PROCEEDINGS OF SOCIETIES. 



21 



After hearing a report of the proceedings of the new com- 
mittee, at the meeting held in Chicago last week, and, after con- 
sidering the changes in the organization which were made, in- 
cluding the restriction of the scope of the membership, by which 
a large proportion of the profession of the country would be 
excluded from the Congress, the following preambles and reso- 
lution were unanimously adopted : 

Whereas, Certain serious changes have been recently effected in the 
preliminary organization and rules for the International Medical Con- 
gress of 1887, it has seemed desirable for the members of the General 
Committee and the officers of the Sections resident in Philadelphia to 
meet for consultation ; and 

Whereas, It has appeared that these changes are inconsistent with 
the original plan, and detrimental to the interests of the medical pro- 
fession in America, and of the International Medical Congress ; there- 
fore be it 

/■ Resolved, That we, the undersigned, consider tbat our duty to the 
profession and to ourselves requires us to decline to hold any office 
whatsoever in connection with the said Congress as now proposed to be 
organized: 

D. Hayes Agnew, S. Weir Mitchell, 

Roberts Bartholow, William F. Norris, 

John H. Brinton, William Gsler, 

Charles H. Burnett, John H. Packard, 

R. A. Cleemann, Theophilus Parvin, 

J. M. Da Costa, William Pepper, 

Louis A. Duiiring, Edward T. Reiciiart, 

William H. Ford, Albert H. Smith, 

William Goodell, Robert Meade Smith, 

Samdel W. Gross, Alfred Stille, 

Robert P. Harris, George Strawbridge, 

I. Minis Hays, William Thomson, 

William W. Keen, James Tyson, 

Joseph Leidy, Horatio C. Wood, 

David W. Yandell. 

Armyllltelligen.ee. — Official List of Changes in the Sta- 
tions and Duties of Officers serving in the Medical Department, 
United States Army, from June 21, 1885, to June 27, 1885 : 
Haetstjff, Albert, Major and Surgeon. Assigned to duty at 

Fort Hamilton, New York Harbor. S. O. 133, Department 

of the East, June 24, 1885. 
Middleton, J. V. D., Major and Surgeon. Granted one 

month's leave, with permission to apply for fifteen days' 

extension, to take effect about the 15th proximo. S. O. 88, 

Department of the Missouri, June 19, 1885. 
Brown, H. E., Major and Surgeon. Assigned to duty as post 

surgeon, Fort Reno, Indian Territory. S. 0. 91, Depart- 
ment of the Missouri, June 24, 1885. 
Taylor, Blair D., Captain and Assistant Surgeon. Ordered 

from Department of Texas to Department of the East. S. O. 

141, A. G. O., June 20, 1885. 
Caster, William F., Captain and Assistant Surgeon. Ordered 

from Department of the East to Department of Texas. S. 

O. 141, A. G. 0., June 20, 1885. 
Davis, William B., Captain and Assistant Surgeon. Leave of 

absence extended three months. S. O. 142, A. G. 0., June 

23, 1885. 

Ebert, R. G., First Lieutenant and Assistant Surgeon. Granted 
leave of absence for one month, to take effect about July 
5th. S. O. 97, Department of the Columbia, June 17, 1885. 

Robertson, R. L., First Lieutenant and Assistant Surgeon. 
Now on leave of absence, directed to report in person by 
July 7, 1885, to commanding officer, Columbus Barracks, 
Ohio, to accompany detachment of recruits to Department 
of Texas. On completion of this duty, to rejoin his proper 
station. S. 0. 143, A. G. O., Juno 24, 1885. 



Society Meetings for the Coming Week : 

Monday, Jluy 6th : New York Academy of Sciences (Section 
in Biology); Morrisania Medical Society (private); Brook- 
lyn Anatomical and Surgical Society (private) ; Utica, N. Y., 
Medical Library Association; St. Albans, Vt., Medical As- 
sociation ; Providence, R. L, Medical Association ; Hartford 
City, Conn., Medical Association; Chicago Medical Society. 

Tuesday, July 7th : Elmira, N. Y., Academy of Medicine; Buf- 
falo Medical and Surgical Association ; Medical Society of 
the County of Broome, N. Y. ; Ogdensburg, N. Y., Medi- 
cal Association; Hudson County (Jersey City) and Union 
County (quarterly), N. J., Medical Societies; Chittenden 
County, Vt., Medical Society; Androscoggin County, Me., 
Medical Association (Lewiston). 

Wednesday, July 8th : American Microscopical Society of the 
City of New York ; Medical Societies' of the Counties of 
Cayuga and Seneca (annual). N. Y. ; Tri-States Medical As- 
sociation (Port Jervis, N. Y.) ; Franklin District (quarterly 
— Greenfield), Hampshire District (quarterly — Northamp- 
ton), and Worcester District, Mass. (Worcester), Medical So- 
cieties. 

Thursday, July 9th : Brooklyn Pathological Society ; Medical 
Society of the County of Fulton, N. Y. (semi-annual — Johns- 
town); South Boston, Mass., Medical Club (private). 

Friday, July 10th: Medical Society of the Town of Saugerties, 
N. Y. 

Saturday, July 11th: Worcester North District, Mass., Medi- 
cal Society. 



proceebings of Societies, 



COLLEGE OF PHYSICIANS OF PHILADELPHIA. 

Meeting of June 3, 1885. 

A Plea for the Medicinal Use of Pure Alcohol and Al- 
coholic Mixtures of Known Composition in Preference to 
Ordinary Fermented Liquids.— Dr. Henry Leffmann read 
the following paper: 

I present to the College this evening, with some misgivings, 
I confess, a topic which can scarcely yet be considered a "live 
issue " in clinical medicine, but which is destined, I am certain, 
to become one. At the present time the profession does not 
take kindly to suggestions having in view material modifica- 
tions of its policy in reference to alcoholic liquors. The ma- 
jority of physicians regard those who preach or practice total 
abstinence, or throw doubt on the indispensability of alcohol 
as a therapeutic agent, as entitled to little respect or tolerance. 
In presenting the view that we should abandon in clinical medi- 
cine the use of the natural wines and liquors, and resort to 
mixtures confessedly fictitious, we must expect to encounter all 
the force of the conservative spirit. Many centuries of con- 
stant use have developed in the race a feeling that fermented 
drinks, particularly those that, like wines and malt liquors, 
have suffered no modification by distillation or admixture, are 
bounties of nature wisely given for our use. The traditions of 
the past associate the first preparation of liquor with the gods r 
and in all ages poetry and prose have combined to increase the 
reverence for these natural products. Yet all this feeling is 
nothing but a superstition. Fermentation is now known to be 
a process occurring under the influence of micro-organisms, and 
it allies itself with ordinary putrefaction. The reverence which 
we have for " Nature's laboratory " is born of ignorance, and 



22 



PROCEEDINGS OF SOCIETIES. 



[N. Y. Med. Jock., 



there is no progress in chemistry more gratifying in its results 
than that which deals with dispelling the illusions which have 
surrounded its application to medicine. 

"Whatever ulterior relations the plan advocated here may 
have to the questions of total abstinence are not presented for 
discussion ; I merely offer it as a contribution to the methods 
of exactness and certainty in clinical work. 

In the medicinal and dietetic use of fermented liquors, it is 
the effect of the ethyl alcohol which is sought to be obtained. 
It is true that those who prescribe liquors a great deal are in 
the habit of saying that the accessory ingredients, compound 
ethers, astringents, or bitter principles, etc., are also efficacious, 
but that, if we closely observe the customs of such prescribers, 
it will be found not only that the effect expected from the 
alcohol outweighs that to be obtained from any other ingre- 
dient, but also that, in the majority of cases, the accessory in- 
gredients are either not known or recognized. 

Taking this fact, then, as a starting point, that an agent uni- 
versally recognized as one of powerful physiological activity 
should be used only in the most definite condition. The forms 
of fermented liquors are numerous, and each form is subject to 
minor variations, depending on locality and season. The de- 
mand exceeds the supply, and hence the strong temptntion to 
dilute and substitute. "Within the past few months further no- 
tice has been given of the communications by American consuls 
abroad to the effect that the wines and brandies exported from 
France and Portugal are fictitious articles, in the majority of 
cases, and it needs but a little inquiry to show that a very large 
trade in liquors more or less spurious is carried on over the en 
tire world. 

Chemical analysis still has much to accomplish in the study 
of fermented liquors, but enough is known to enable us to imi- 
tate their essential features. The tabular statement of compo- 
sition gives us a long list of mineral ingredients, but we are rea- 
sonably certain that, besides the ethyl alcohol, the only ingre- 
dients that need attention are the traces of fusel oil, compound 
ethers, astringent and bitter principles, and the effect even of 
their accessories is often more on the mind than on the body. 

I suggest first, then, that in all cases in which the general 
physiological effect of ethyl alcohol is desired, it should be given 
hy prescription, in the form of a rectified spirit of standard 
strength. My friend, Dr. A. W. Miller, who is familiar witb 
this topic, both from the point of view of the pharmacist and 
physician, has suggested that such a standard, pure spirit be 
made officinal under the title spiritus maydis rectvficatus. Such 
a suggestion is in the interest of clinical accuracy and safety to 
the patient. If the medical profession have any concern in the 
protection of the health and morals of the community — and it 
would certainly appear that it has great concern — no better op- 
portunity ia offered for good work than in reforming the wide- 
spread errors in reference to the use of alcoholic liquors. Where 
is the physician who would say to a patient, Take a little lauda- 
num or chloral every day, and leave to the patient or the drug- 
gist the duty of determining the dose, or the duration of the 
treatment? Yet every day physicians give similar recommenda- 
tions in regard to liquors. The use of rectified spirits in pre- 
scriptions is to be recommended on the same ground that we 
give potassium bromide and iodide in accurate dosage, instead 
of the sea-water which contains them, or morphine and quinine 
instead of opium and Peruvian bark. Incidental to the thera- 
peutic accuracy and moral safety which are involved in such 
practice is the not unimportant question of cheapness. Many 
liquors command prices far above the actual commercial value 
of the ingredients they contain. A pure French brandy, for in- 
stance, costs twelve dollars a gallon. Its place can be taken by 
a spirit of much less cost. 



Several objections may be made to the plan of using the 
plain spirit. I can not stop to consider the one which arises 
from a belief in the superiority of a natural product, from a 
view that that which arises from a natural process will be 
necessarily superior to anything artificial ; this, as I have said 
before, is a superstition ; but there are some suggestions which 
are really important. It may be that the accessory ingredients 
have some therapeutic value, and it has been said to me that 
while pure alcohol may easily be used during acute disease and 
in hospital practice, that in long-continued treatment, and as a 
dietetic, patients can not be made to take it. In these cases the 
method to be pursued is plain. Let the alcohol be mixed with 
suitable accessory ingredients. If a combination of bitter tonic, 
sedative, and stimulant is wanted, it can be prescribed, and so 
on. There need be no difficulty in the matter, because modern 
art in the preparation of fictitious liquors has reached such per- 
fection that excellent imitations of the natural liquors are made, 
and these have the advantage of definite and known composi- 
tion and greater cheapness. 

It is not uninteresting to note here the general nature of 
this work. I have the samples to illustrate it. In the prepara- 
tion of fictitious liquors three methods maybe employed. 1. 
The genuine liquor may be diluted with a suitable strength of 
pure spirit. This will give us a liquor differing but little from 
the original. 2. The liquor may be imitated by adding to 
pure spirit coloring and flavoring ingredients. In many cases 
this will give a liquor substantially identical with the original. 
3. The liquor may be made up weak, and then taste and appear- 
ance of alcoholic strength be given by means of pepper and 
bead oil. The latter method is reprehensible, but the two for- 
mer methods are, I hold, not injurious, and should be recog- 
nized. 



OBSTETRICAL SOCIETY OF PHILADELPHIA. 

Meeting of June 4, 1885. 

The President, Dr. B. F. Baer, in the Chair; 
Dr. W. H. H. Githens, Secretary. 

Biniodide of Mercury as a Disinfectant in Obstetrics.— 

Dr. E. P. Bernardy read a paper with this title. His attention 
had first been called to the use of the biniodide of mercury as a 
germicide by Dr. Miquel, who had published in "L'Annuaire 
met6orologique de Montsouris" the results of some experiments 
made to determine the minimum amount of a disinfectant ne- 
cessary to prevent fermentation in a litre of sterilized beef-broth. 
His experiments showed that the mercurials were the best anti- 
septics, the biniodide being nearly three times as strong as the 
bichloride. In his table of disinfectants he placed the bichloride 
fourth on the list. To a litre of sterilized beef-broth he found 
it required 0 - 025 gramme of the biniodide of mercury to keep 
the broth pure, while 0 - 070 gramme of the bichloride of mer- 
cury was necessary to produce like effects. This showed that 
bacterial life was impossible in a solution of one forty-thou- 
sandth part of the biniodide, while of the bichloride it required 
one fourteen-thousandth part. The reader had been so forcibly 
impressed with these experiments that he had determined to 
give the biniodide of mercury a trial in obstetric cases where it 
was necessary to use an antiseptic. The following were the 
cases in which it had been used : 

Case I. — On February 7, 1885, he was requested to take charge 
of Mrs. D., who had been confined about six weeks previously. It 
had been her second confinement, the duration of labor had been 
short and delivery natural, but an extensive laceration of the peri- 
naeum had occurred. No attempt had been made to bring the 
parts together by sutures. On the third evening she had been at- 



July 4, 1885.| 



PROCEh.DINOS OF SOCIETIES. 



23 



tacked with severe frontal headache and chills, followed by fever, with 
great tenderness over the region of the uterus. There being no im- 
provement in her condition, her medical attendant was discharged, and 
another called in, who gave such an unfavorable prognosis that he also 
was requested to cease his attendance. The patient had well-marked 
symptoms of septic poisoning. The pulse ranged from 130 to 140, 
was small and thready, and disappeared under the pressure of the 
finger; the temperature was 104° to 105°. She was slightly delirious, 
and had constant vomiting; the abdomen was swollen and excessively 
tender ; the uterus was enlarged, extending fully three inches above the 
pubes. In the right side there seemed to be a growth extending up 
into the abdomen, tender on pressure. On making a vaginal examina- 
tion, the os was found dilated so that the index-finger could readily enter 
the uterus. Its withdrawal was followed by a gush of highly offensive 
matter. The uterus was surrounded by organized lymph, and was im- 
movable. The mass on the right side was easily detected, and was 
continuous with the lymph surrounding the uterus. The vagina was 
hot. The perinaeum was torn to the anus ; the surface was raw and 
discharged an acrid matter which scalded the surrounding parts. The 
urine was dark, .and, on standing, deposited a reddish material which 
looked like blood-corpuscles. Dr. A. E. Russell examined the specimen 
and reported it to be slightly acid, with no albumin or sugar ; under the 
microscope occasional pus-corpuscles were seen, and it was swarming 
with bacteria. In conjunction with internal treatment, intra-uterine 
injections were made three or four times a day. A solution of bi- 
chloride of mercury, 1 to 2,000, was first used. This was continued 
for three days without any marked results. The discharges continued 
as offensive as before. On the fourth day the bichloride was replaced 
by a l-to-4,000 solution of biniodide of mercury. Within twenty-four 
hours an amelioration of all symptoms took place, the pulse fell to 100, 
and the temperature to 101° ; the urine became clear and the discharge 
odorless. The injections were continued for ten days, their frequency 
being gradually reduced. The uterus returned to almost its normal size, 
and the lymph was gradually absorbed. The patient recovered. 

Case II. — March 19, 1885, he was called to attend Mrs. W. in her 
first confinement. On his arrival, he found she had been in labor sev- 
eral hours. Examination showed the os perfectly dilated and the bag 
of waters protruding. The presentation was of the vertex, in the first 
position, and he ruptured the amnion. The vagina near its outlet was 
roughened with venereal warts, and they spread also over the vulva. 
Labor progressed rapidly and the second stage was happily ended. 
After waiting nearly an hour, making pressure on the uterus, he made 
slight traction on the cord, and, while doing so, felt, with his hand 
upon the uterus, a cup-like depression of the fundus take place. This 
convinced him that he had an adherent placenta to deal with, and that 
it would be folly to wait any longer. On introducing the hand he 
found the placenta completely adherent, so that it could hardly be said 
which was uterus and which placenta. After considerable trouble, he 
at last succeeded in detaching the piacenta ; it took fully three quarters 
of an hour. On making a second examination, to ascertain if the whole 
had been removed, his hand came in content with long shreds hanging 
from all sides of the uterus ; the more he scraped, the more there 
seemed to be. He gave the patient two drachms of fluid extract of 
ergot. She did well for two days, when toward evening she complained 
of a chill and severe frontal headache. He then gave her ten grains of 
sulphate of quinine, with a quarter of a grain of sulphate of morphine, 
at one dose, and washed out the uterus with a l-to-4,000 solution of 
biniodide of mercury. The pulse was 115 and the temperature 102°. 
The discharge was highly offensive. The injections were repeated every 
four hours. On the evening of the next day the pulse was 98, the 
temperature 100°, the discharge odorless, and the patient was perfectly 
well in ten days more. 

Case III. — April 23, 1885, he was requested to call at once to see 
Mrs. K., who was reported in imminent danger of death. This was her 
ninth confinement. The history of the previous ones, with one excep- 
tion, was not good. Her labors had been natural, but followed by ter- 
rible flooding and protracted convalescence. He found her in an attack 
of puerperal convulsions. He gave at once thirty grains of bromide 
of potassium and twenty of chloral hydrate. This dose was re- 



peated in half an hour ; ten minutes later another convulsion occurred. 
He then bled the patient freely. The os uteri was somewhat enlarged, 
the cervix soft and dilatable ; there was a vertex presentation. Dr. 
Curtin, whom he had sent for, having confirmed his opinion, and con- 
sidering that the patient's time was quite up, it was decided to etherize 
her, dilate the cervix, and deliver. The forceps was applied, and trac- 
tion made at intervals. A living child was safely extracted. Continu- 
ous pressure was maintained over the uterus, but, after the expulsion of 
the placenta, the organ did not contract until it had been washed out 
with hot water. The bromide and chloral were continued every two 
hours, and no more convulsions occurred. The patient did well up to 
the fourth day, when the discharges became very offensive and the 
pulse accelerated, and slight tenderness existed over the uterus ; but 
there was no chill or fever. The uterus was thoroughly washed out 
with a solution of biniodide of mercury, 1 to 4,000, and within twenty- 
four hours the discharge had become odorless and the tenderness over 
the uterus had disappeared. The patient recovered after a tedious con- 
valescence. 

In these cases it would be seen that the biniodide was 
prompt in its action, markedly so in Case I, where the bichlo- 
ride and the biniodide were both employed, the result being 
decidedly in favor of the biniodide. Naturally, it would be 
said, here were only three cases from which deductions were to 
be drawn, and it was only after it had been carefully used in a 
large number of cases that its efficacy could be proved. It was 
for this reason that he brought it to the attention of the mem- 
bers of this society, who were in a position to give it a fair and 
impartial trial, and at some future time give the results of their 
investigations. He bad found the l-to-4,000 solution of the bin- 
iodide non-irritating, and had used it extensively in his gynas- 
cological practice and in washing out pus cavities with good re- 
sults. In it we had a preparation in which the smallest amount 
of drug was used with results far exceeding those of any other 
antiseptic. On account of the small quantity of mercury, there 
would be less chance of salivation. The method he had pursued 
in makiDg the solution was : Take three grains and a half of the 
salt, well triturated in a mortar and rubbed, with one quart of 
boiling water, slowly added, giving a solution of 1 to 4,390. 
Since writing the foregoing he had seen in the " Philadelphia 
Medical Times" for May 16th that Dr. Panas, eye surgeon of 
the Hotel-Dieu, used the l-to-25,000 solution of biniodide of 
mercury in eye cases. He made the following statements: 
" After a number of experiments, I have convinced myself that 
a solution in water, 1 to 10,000, of the bichloride, or a similar 
solution, 1 to 25,000, of the biniodide of mercury, is much supe- 
rior to any other antiseptic solution employed in eye surgery.' 
Here again we had a statement that the biniodide in a smaller 
quantity was as good an antiseptic as the bichloride. 

Dr. Montgomery's experience had led him to the conclusion 
that the bichloride of mercury was far more effective as a disin- 
fectant than carbolic acid. Its introduction into the Philadel- 
phia Hospital had been due to Dr. Parvin, who had found it 
very satisfactory. In eighteen cases of puerperal fever that were 
treated with bichloride injections, only three deaths occurred. 
This success was attributed by the hospital staff to the use of 
the bichloride. In private practice the speaker followed the 
plan of Dr. Garrigues, of New York, and avoided intra-uterine 
injections after labor, but applied pledgets wet with a bichloride 
solution over the vulva, after carefully cleansing away clots and 
washing the external parts with a similar solution. In his last, 
term at the Philadelphia Hospital he had bad only two eases of 
puerperal fever, one of which commenced twelve days after de- 
livery. The history of Dr. Bernardy's cases showed an equal if 
not better antiseptic power in the biniodide of mercury. 

Dr. J. V. Kelly some years ago had had several fatal cases 
of puerperal fever, and about twenty-five patients that got well. 



24 



PROCEEDINGS 



OF SOCIETIES. 



[N. Y. Med. Jor k., 



The trouble commenced in a case of abortion, in which he did 
not succeed in removing all of the placenta. He was at the same 
time attending a bad case of erysipelas, and at that time the 
relationship of puerperal fever and erysipelas was not known to 
bim. He was on the point of giving up his practice and leaving 
the town, and he consulted Dr. Goodell on that question. Dr. 
Goodell discountenanced such action, but advised him, when 
attending an obstetric case, to remove bis coat and roll up his 
sleeves, and wash his hands and arms well with turpentine, using 
the nail-brush thoroughly. Since that time he had washed his 
hands in turpentine every day and again before every case of 
labor. He also used a wash of vinegar or carbolic acid solution 
before touching a puerperal patient. He had met with no puer- 
peral fever or other septicemic symptoms since that time. 

Dr. Parvin said that, as reference had been made to his 
having used corrosive-sublimate vaginal injections in the cases 
of puerperal septicaemia under his care in the Philadelphia Hos- 
pital last year, he would refer to the antiseptic treatment in the 
cases occurring the present year. When he took charge of the 
obstetrical ward, on the 1st of January, he found five recent 
cases of septicaemia: two of these patients died; one of the two 
had apparently recovered and then was attacked by pneumonia 
— quite possibly this pneumonia had a septic origin. Then 
there were at least seven other cases, but all these patients, as 
well as three of the original five, recovered. Injections of a 
solution of corrosive sublimate, 1 to 5,000, were used in all 
cases immediately after labor. The external parts were washed, 
too, with a similar solution. This injection was repeated twice 
a day in all cases for the first week after labor, while it was used 
oftener in those having septicaemia. Intra-uterine injections were 
used only when vaginal injections failed to correct the offensive- 
ness of the discharge, but, as was well known, there might be 
serious, even tatal, cases of septic disease though the lochial How 
was not at all offensive. In private practice, after once wash- 
ing out the vagina thoroughly with the antiseptic solution im- 
mediately after labor, this need not be repeated unless symp- 
toms demanded it, but the bathing of the vulva twice a day 
with the solution ought not to be omitted. Add, if preferred, 
to this treatment the use of antiseptic napkins, a practice pur- 
sued by Dr. Montgomery at the Philadelphia Hospital so suc- 
cessfully, and he thought we had taken the most important 
means to guard against the entrance of septic germs after labor. 
He had had no experience with the biniodide of mercury, and 
did not know that it would supersede the bichloride. The ar- 
gument in its favor was as strong as three successful cases 
could make it, but these were entirely too few, as Dr. Bernardy 
had justly said, to prove its value and its superiority. In one 
of the doctor's cases labor was induced, apparently on account 
of eclampsia. Now, was this the best treatment? Obste- 
tricians were by no means agreed, some of the best condemning 
such treatment. 

Dr. Montgomery used the bichloride solution as an externa] 
wash only, not as an injection. He thought the records of the 
hospitals in which injections were used would not show such 
good results as those in which they were omitted, if septicaemia 
was not present. 

Dr. Wh.lard had a warning to sound with regard to the use 
of strong bichloride solutions. He had been using washes and 
antiseptic dressings made with a l-to-1,000 solution of bichlo- 
ride, but, in consequence of what had been written about the 
advantages of stronger solutions, he had increased the strength 
to 1 to 500, and within twenty-four hours the stools contained 
bloody mucus, and were small and griping; there was vesica- 
tion about the wound and around the limb under the dressings. 
Entirely dry dressings had been used, but they had been moist- 
ened by pus and serum from the wound. He did not see the 



advantage of solutions in serum so strong as 1 to 100 or 75. 
Serum was a decomposable substance, and an uncertain portion 
of the antiseptic agent was destroyed by it. Weak solutions in 
boiling water seemed more reasonable, and answered every pur- 
pose. 

Dr. Longaker would like to hear how Dr. Bernardy re- 
moved the placenta in the case of adhesion narrated by him. 
He had been using Crede's method with great satisfaction, lb- 
thought the hand should be kept out of the parturient canal as 
much as possible. He did not use vaginal injections after labor, 
but depended upon outside washes. He found that the tem- 
perature rarely rose during the puerperal period, even after in- 
strumental delivery. He thought care during the third stage 
would avoid the necessity for antiseptics. 

Dr. Parish agreed with Dr. Parvin's views. He had found 
a solution of 1 to 1,000 of bichloride irritating, and he now used 
one of 1 to 2,000 or 5,000. Strong solutions caused an appear- 
ance resembling erysipelas or inflammation of the derma. In- 
jections were not necessary in every case. Where the surround- 
ings were cleanly and the patient was a multipara he did not 
use them ; but in primiparas, with contusions or lacerations, and 
when version or instruments had been employed, he was in the 
habit of injecting a weak solution of bichloride immediately 
after delivery. He did not repeat it, but simply washed out the 
vagina. Cleanliness of hands, instruments, and nurse was the 
most important point. He had never had any trouble in private 
practice. 

Dr. Bernardy, in closing the discussion, remarked that he 
thought he had a far better antiseptic in biniodide than the bi- 
chloride. He had used the former in surgical cases also, for 
washing out pus cavities, and always with good results. He did 
not use intra-uterine washes in every case of labor. He had at- 
tended, since the first of the year, about seventy cases of labor, 
and he had employed the intra-uterine injections in only the 
three cases detailed. In every case of labor he used carbolic- 
acid soap on his hands and arms and the external genitalia of 
the patient. The eclamptic patient had reached or passed ber 
full term, and there was no reason why the child should not be 
removed. In the case of adherent placenta it was peeled off for- 
cibly and a shreddy lining was left in the uterus, as no line of 
separation had formed. He believed the dangers consequent on 
passing the hand and arm into the uterus and vagina were much 
exaggerated, and he did not hesitate to do so when the exi- 
gencies of the case demanded it. 

(7b be concluded.) 

NEW YORK OBSTETRICAL SOCIETY. 

Meeting of January 20, 1885. 

Dr. W. M. Chamberlain Chairman pro tern. 

A Spiral Tenaculum was presented by Dr. James B. Hun- 
ter, who had found it especially useful in operations for fistulas 
within the vagina and for repairing the perinseum and cervix 
uteri. The instrument retained its grasp upon the tissues more 
firmly than the ordinary tenaculum, and was easily engaged and 
disengaged. 

A Soft-Rubber Female Catheter was also presented by 
Dr. Hunter. The opening was at the extremity of the tube, 
and the walls gradually increased in thickness toward one end. 
He had known nurses to set up a urethritis or cystitis by the 
use of rigid catheters after minor operations, which was more 
troublesome than the original disease. He never employed the 
silver catheter, because of the danger of the mucous membrane 
becoming engaged in the orifice and being injured. 

The Chairman thought the spiral tenaculum might enable 



July 4, 1885.J 



PROCEEDINGS OF SOCIETIES. 



25 



us to avoid hacking the tissues, which sometimes took place 
when the ordinary tenaculum failed to retain its grasp. With 
regard to the rubber catheter, he asked if it would not in some 
cases be too soft. 

Dr. Hunter said that when a firmer instrument was required 
the ordinary rubber male catheter could be used. 

Removal of the Ovaries and Tubes for Extreme Dys- 
menorrhcea and Mania.— Dr. B. F. Dawson presented the 
Fallopian tubes and ovaries removed two days before from a 
patient with the following history : She was thirty-six years of 
age, from New Jersey, had been suffering from apparently hys- 
terical symptoms for two years, and from dysmenorrhoea, which 
became more aggravated at each return of the menstrual flow. 
Dr. Dawson first saw her eighteen months ago, but was unable 
to make a satisfactory examination of the pelvic organs because 
of hyperaasthesia and symptoms of hysteria. Two months after- 
ward he made another examination, and found tenderness over 
the region of both ovaries, but the patient's condition was still 
such as to forbid a thorough exploration of the pelvic organs. 
She then passed into the hands of a physician prominent in the 
treatment of nervous diseases, who stated that her symptoms 
were due 'to simple hysteria and nervous disturbance. But she 
grew worse, and became the subject of marked convulsive seiz- 
ures, and two months ago was advised to come to New York for 
further examination and treatment for disease of the sexual 
organs. December 29th her physician, Dr. Allen, wrote Dr. 
Dawson that she was in one of her periodical attacks, and had 
for four days been lying in a maniacal state. He advised that 
an operation be performed for her relief before the return of 
another menstrual period, as it was feared she would not be able 
to live through another attack. The patient arrived in New 
York on Saturday night, pulseless at the wrist, the extremities 
cold, the mind lethargic. There was ovarian enlargement with 
tenderness. After a consultation it was decided to operate the 
next morning, but, when morning came, two hours were spent in 
stimulating the patient, to put her in a condition at all suitable 
for an operation. It was probable that not more than a wine- 
glassful of blood was lost during the operation. The right ovary 
was removed with some difficulty. The left one was as large as 
a hen's egg, and bound down by adhesions. While he was 
endeavoring to liberate it it burst in his hand, and material 
escaped which felt like lumps of charcoal. It proved to be a 
black, granular mass, probably composed of coagulated blood 
which had become encysted within the tumor. This ovary also 
contained several cysts, and both organs were in a state of con- 
gestion. The patient rallied well just after the operation, her 
mind was clear, and she said she felt better than for many 
months, and confidently believed that she would recover. But 
the following morning the temperature rose to 105 - 5° F., and, 
although it was readily reduced temporarily by the coiled tube 
conveying water, it would again rise, and death seemed inevita- 
ble. At 4 p. m. the pulse could scarcely be felt at the wrist. By 
request, Dr. Howe transfused about three ounces of blood and 
an equal quantity of salt and water. But neither the pulse nor 
the respiration showed any marked improvement, and she died 
in the morning. Death might have been accelerated by shock, 
but it was thought to be chiefly due to inanition and loss of 
nerve power resulting from protracted illness. 

Dr. Dawson was of opinion that the blood-clot removed 
from the left ovary was formed at the last menstrual period, 
when it was feared that the patient would die. He attributed 
her symptoms to the condition of the ovaries, and said that, had 
an operation been allowed when he urged it six months ago, the 
patient would have stood a better chance of recovery, and would 
have been spared months of extreme suffering. 

Dr. A. Jaoobi said that, in order to complete the history of 



the case, one or two things would be desirable. One was, recov- 
ery after the operation ; another, since the patient had died, a 
post-mortem examination, and he would suggest that, if it was 
possible, one should yet be made. Those who had listened to 
the history had not seen the patient; certainly Dr. Dawson had, 
and he had given reasons why he had regarded the symptoms as 
of reflex origin, and therefore had operated upon the ovaries. 
But possibly an autopsy would give a clew to the origin of the 
symptoms, as it had done in some other cases, in a direction dif- 
ferent from that to which Dr. Dawson had pointed. He would 
not say that this was one of the cases, but meningitis, more or 
less localized and more or less old, had given rise to a great 
many symptoms which had very frequently been mistaken for 
reflex symptoms. He therefore thought that a post-mortem 
examination would be very important in order to determine 
absolutely that there was nothing in the brain which might 
explain the symptoms. If nothing was found in the brain he 
would certainly be of the same opinion with Dr. Dawson, that 
the ovaries were the cause of all the symptoms complained of 
for so many years. 

Dr. Dawson remarked that the maniacal symptoms dated 
back only a few menstrual periods, and that after the operation 
the patient became clear in her mind. The history was not one 
of meningeal trouble. 

Dr. Jacobi said there were many cases of meningitis which 
did not show pathognomonic symptoms. He did not think our 
knowledge of reflex symptoms was sufficiently advanced to en- 
able us always to exclude disease of the central organ of which 
we knew so little. 

Dr. Dawson said that a year ago, at the request of Dr. C. 
H. Brown, he saw a woman with mania, in whom he detected 
an enlarged ovary, and, inasmuch as there was a possibility of 
the mental trouble being of reflex origin, he advised an opera- 
tion, which was consented to. The specimen was shown to the 
society. He saw the woman about six weeks ago, and her hus- 
band told him that she was herself again, and absolutely free 
from maniacal symptoms ; the operation, he said, had cured her. 
A month ago, however, her symptoms of mania had returned. 
This case would go to support the view taken by Dr. Jacobi 
that we were in ignorance of the influence which disease of the 
ovaries might have in the production of mania. 

Dr. Hunter thought that time enough was not always al- 
lowed to elapse after removal of the ovaries before denying its 
beneficial effect. He recalled a case operated upon by Dr. 
Thomas some years ago for the relief of maniacal symptoms for 
which the patient had been restrained nearly a year. Both 
ovaries were found to be diseased, but no improvement fol- 
lowed their removal ; the patient became a hopeless maniac. 
But, after the lapse of a number of months, improvement began, 
and now, two years after the operation, the patient was perfect- 
ly well. She had been a burden to her household for ten years. 
Dr. Hunter had seen several other cases in which recovery did 
not begin to take place for from twelve to eighteen months after 
removal of the ovaries for symptoms attributed to disease of 
those organs. 

Dr. Jaoobi inquired of Dr. Hunter whether he attributed 
the patient's improvement eighteen months after the operation 
to removal of the ovaries. 

Dr. Hunter replied that that was the deduction ; there was 
no question as to disease of the ovaries ; they were both cystic. 
The symptoms of mania began with dysmenorrhea, and were 
aggravated during each menstrual period. 

Dr. Jaoobi thought that such cases ought to be accepted 
with a good deal of doubt. Eighteen months was a long time 
to wait after an operation for recovery to take place ; he did 
not think that so great a length of time should be required for 



26 



MISCELLANY. 



[N. Y. Med. Joub., 



the absorption of inflammatory deposits which might have oc- 
curred in the neighborhood of the diseased organs and caused a 
continuance of the symptoms. Besides, there were many cases 
of mania which got well without removal of the ovaries, and 
cases of the kind related by Dr. Hunter should not, therefore, 
be allowed to prove too much in favor of the operation. 

Dr. Hunter remarked that in the case to which he referred 
menstruation had continued with more or less regularity a year 
or two after the operation. He had records of cases in which 
menstruation had continued for about a year after the opera- 
tion. If the periods continued to recur for a year, it was not 
unreasonable to suppose that improvement would begin at the 
end of that time. He believed, with Dr. Jacobi, that it would 
require a number of cases to prove the matter positively. 

The Chairman inquired whether we were to understand that 
the improvement began with the cessation of menstruation. 

Dr. Hunter replied in the affirmative. He further referred 
to a case of which he had very full records — that of a woman 
who had suffered from dysmenorrhcea of increasing severity for 
eight years. She preferred death to her condition before the 
operation. No marked improvement followed the removal of 
the ovaries, and at the end of six months she was still suffering 
from severe pain. At the close of the year, however, she wrote 
that she was perfectly well. She menstruated about the elev- 
enth month after the operation. One ovary had been found to 
be enlarged and cystic, and both tubes were enlarged. 

Prolapsus of the Rectum— Dr. A. Jacobi related the his 
tory of a case of prolapsus of the rectum in a child nearly three 
years of age, which was presented at his clinic recently. As it 
entered the room it walked a little peculiarly, as if suffering 
from soreness of the inguinal glands. It was unable to have a 
movement from the bowels without straining, and in the pas- 
sage of both fasces and urine was obliged to lie upon the belly 
and face. Dr. Jacobi attempted to place the boy upon a chair, 
but he struggled against it, and his mother said he was unable 
to sit. On letting his pantaloons down it was observed there 
was prolapsus of the rectum a distance of three inches, present- 
ing the appearance of a sausage of a dark- red hue. The protru- 
sion bled very easily when touched. At the outer end was an 
opening, into which he inserted his thermometer-case to take 
the measurements. As the silver case passed the anus it was 
grasped rather tightly, which would explain why there had 
been difficulty in having passages. This condition had lasted 
for three weeks. An attempt had been made at reduction, but 
unsuccessfully. Dr. Jacobi supposed the intestine, being so 
tightly grasped by the anus, could not be in a healthy condi- 
tion, and, on examining the parts with great care, he found that 
at the seat of the constriction there were numerous cuts, with 
rough edges, of varying depth, some extending as deep as the 
peritoneal coat, showing that amputation of the protruded gut 
was gradually taking place. He certainly would not undertake 
reposition at the college clinic-room, and, accordingly, had the 
child sent to Mount Sinai Hospital, there to be kept under ob- 
servation. It seemed wiser to allow the colon to become gradu- 
ally amputated than to undertake reduction, in view of the lia- 
bility of tearing the exposed peritonasum. He drove to the 
hospital himself shortly after the child was sent, to instruct the 
house physician to do nothing in the case except under his 
directions or those of the physician in charge. He was told the 
next day that one of the assistants, on seeing a case of prolapsus 
of the rectum enter the wards, availed himself of the absence of 
the house physician, and squeezed and handled the parts long 
enough to reduce the protrusion. The next day the child had 
some difficulty in passing fasces, but the difficulty disappeared 
by the third day. Little or nothing that was peculiar could 
be felt in the rectum ; probably the incarcerated parts were 



too high to be reached. But the patient was unable to pass 
urine, and the catheter had to be used. Six or seven days 
afterward, learning that the elastic catheter had been used two 
or three times daily by the nurse in the presence of the house 
physician, Dr. Jacobi told the physician to employ a silver 
catheter so that the bladder could be properly explored. A 
good deal of difficulty was experienced in introducing the cathe- 
ter ; the bladder was bent at its neck, and some force had to be 
employed to overcome the obstruction. Before the catheter was 
withdrawn the curve was turned, which straightened the canal, 
and no further difficulty was experienced in urination. It was 
not easy to say what had caused the flexion of the neck of the 
bladder to become aggravated on the reduction of the prolapsed 
rectum. It could not very well have been caused by peritonitic 
adhesions, for the reason that one introduction of the silver 
catheter, with anteflexion of the bladder to the normal or nearly 
normal position, was sufficient to relieve the trouble. While 
the child at present seemed to be quite well, an important ques- 
tion arose as to what would be the final result in the case. It 
was hardly possible that a considerable amount of cicatrization 
would not take place where there had been partial amputation 
of the gut, and it seemed more than probable that in the course 
of time the child would suffer from stricture of the intestine. If 
this should occur, the case would be a difficult one to treat, 
because of the marked sigmoid flexure which existed in chil- 
dren. Had spontaneous amputation taken place the child would 
have been under his immediate observation, and it was not 
probable that it would have been attended by any serious danger, 
inasmuch as a portion of the gut was sometimes successfully 
amputated in intussusception. 

The Chairman thought there was at present danger of faecal 
matter becoming lodged in some of the cuts within the intes- 
tinal coats, and producing further injury. 

Henry J. Garrigues, M. D., 

B. F. Dawson, M. D., 

Frank P. Foster, M. D., ex officio, 

Committee on Publication. 



The Albany Alumni Lectures. — The " Albany Medical Annals " an- 
nounces that the next course will be given on the 3d of March, 1886, 
by Professor S. Oakley Van der Poel, M. D., LL. D., of New York, on 
" Hygiene ; its Relations to the Profession and the General Public." 

The Republic of Guatemala owes a debt of gratitude to a physician 
of this city, who, according to the " Eastern Medical Journal," has pre- 
sented a collection of serpents to the American Museum of Natural 
History which consists of " all the serpents of the Republic of Guate- 
mala." Surely an easier way of ridding a country of snakes can 
scarcely be imagined, although our contemporary does not give us the 
modus operandi by which it was accomplished. 

Infectious Endocarditis. — We are indebted to Dr. John H. Musser 
and Dr. George A. Piersol, of Philadelphia, for a copy of their pam- 
phlet entitled " Notes of a Case of Infectious, so-called Ulcerative, En- 
docarditis, and of a Case of Acute Pericarditis," extracted from the 
" Transactions of the College of Physicians of Philadelphia." It has 
seldom been our fortune to meet with so satisfactory a clinical study, 
and we would particularly commend the photographs, by Dr. Piersol, 
which accompanied the copy sent us. They seem to represent the per- 
fection of the photographic art as applied to medicine. 

The French Medical Year-Book. — We have received from the pub- 
lishers, the Messrs. E. Plon, Nourrit et Cie., of Paris, the seventh vol- 
ume of the " Annee medicale," for the year 1884. This excellent pub- 



July 4, 1885.] 

lication, edited by Dr. Bourneville, the redacteur en chef of the " Progres 
medical," with the collaboration of a number of eminent practitioners, 
furnishes a resume of the progress of medicine during the year. It 
is divided into departments corresponding to the practical branches, and 
an excellent index makes it easy of reference. 

Parturition and Measles. — Dr. A. R. Simmons, of Ithaca, N. Y., 
writes as follows: "On the morning of March 22d I first saw the pa- 
tient. On Friday morning, the 20th, she had complained of headache 
and sore throat, and the next day she had begun to cough. That night 
labor pains set in and continued all night. The next morning I found 
the mouth of the womb patulous, but the pains had nearly ceased. The 
conjunctivae, the roof of the mouth, and the throat were then reddened, 
and she coughed a little. Labor pains began again about 6 p. m., and 
the child was born about 1.30 a. m. It was a normal labor in every re- 
spect, and the signs of measles were then very prominent. Seven 
hours afterward the measles rash was out on her face and neck, there 
was some delirium, the pulse was 128, and the temperature was 104° F. 
I was obliged to catheterize her, and continued to do so until April 3d ; 
the expulsive power and the desire to urinate were wanting. The aver- 
age daily quantity of urine was about a pint, and it contained no albu- 
min or casts. On the 24th the pulse was 108, and the temperature 
100°; the tongue was moist. She had passed a very good night, but 
with some delirium. The rash covered the whole body ; the cough was 
severe, the result of the usual bronchitis ; there was some soreness over 
the bowels, but pressure was very well borne ; the lochia were normal ; 
the bowels had moved. At night the pulse was 100, and the tempera- 
ture 101-3°; there was no tympanites. On the 27th the temperature 
was 100'8°, and the pulse 120; there was no tenderness of the abdo- 
men, but her back ached ; the lochia were offensive, but normal in 
quantity ; the breasts were full of milk. In the afternoon the tempera- 
ture was 99°, and the pulse 100 ; a free movement of the bowels had 
been secured, which had relieved her. From this time she convalesced 
rapidly, and was sitting up on the sixteenth day after delivery. 

"I consider that there was no possibility of error v in the diagnosis of 
measles ; a very extensive epidemic was raging at the time, and a case 
had occurred in the same house early in the month. Knowing that the 
pregnant woman had not had measles, I advised her removal from the 
house, but it was not done. The baby coughed some on the 29th and 
30th of March, and a rash appeared on the latter day, but, when I saw 
it at night, it was hardly perceptible, and it was all gone the next day. 
The child had a convulsion on the 2d of April, but, has since been well. 
I will add that in the same epidemic a child seven weeks old had the 
measles a week after its mother was attacked. Both recovered." 

Congenital Dislocation of the Patella. — A correspondent writes 
from Louisville, inclosing a letter from a former pupil of his, asking for 
information bearing upon the following case : A girl, seven years old, 
having loose joints, although in robust health, has the patella resting 
on the external condyle. It is easily replaced while the limb is ex- 
tended, but requires considerable force to keep it in place during flex- 
ion. Both limbs are affected alike. The girl's father, her aunt, and 
the aunt's daughter, all have their patellas resting on the outer condyle. 
The doctor asks : Can anything be done to rectify the deformity, what 
can be done, and is there anything in literature in regard to such an 
hereditary deformity ? 

Prevailing Diseases in Illinois. — A correspondent writing from 
Stillwell, 111., says that he has encountered an " epidemic " of inflam- 
matory rheumatism and one of paralysis in both children and adults ; 
also that he has regularly to contend with typho-malarial fever in the 
autumn and cholera infantum in the summer. He would be glad to 
receive hints as to the management of these various affections. 

A Correction. — We regret that an error crept into our report of the 
proceedings of the recent annual meeting of the Illinois State Medical 
Society. In the issue for June 20th, page 701, we gave an abstract of 
a paper entitled '' How the Vitality of a Seed is Preserved," and credited 
the paper to Dr. H. Judd, of Galesburg. The paper, we now learn, was 
really read by Dr. A. Wetmore, of Waterloo, and we take pleasure in 
making the correction. 



27 

THERAPEUTICAL NOTES. 
Veratrum Viride in the Treatment of Palpitation. — M. See (" Union 
med." ; " Dtsch. Med.-Ztg.") recommends the use of tincture of vera- 
trum viride for controlling over-action of the heart in cases of exoph- 
thalmic goitre. From three to five drops are to be given three or four 
times a day, for several weeks or months together. 

Persian Insect Powder as a Medicine. — The "Deutsche Medizinal- 
Zeitung" alludes to the fact that a Russian physician, Dr. Swiontezki 
has lately recommended an alcoholic extract of Persian insect powder, 
with the addition of santonin, as a " sure cure " for cholera ; and then 
quotes from another Russian source to the effect that enemas of the 
insect powder are effective in the treatment of ascarides, and have no 
poisonous action. 

Massage in the Treatment of Faecal Accumulation. — Kriwjiikin 
(" Protok. der kankasisch. med. Gesellsch." ; " Dtsch. Med.-Ztg.") re- 
ports four cases of obstinate constipation, varying from eight to twelve 
days in duration, in which the trouble was overcome by deep massage. 
The fingers, previously oiled, are to be pressed firmly upon the abdo- 
men, and movements of massage are then to be executed, especially 
upon those parts where hardened masses are felt. The process is to be 
continued for twenty minutes, and repeated at intervals of an hour and 
a half until the bowels are moved. 

Strychnine in the Treatment of Supra-orbital Neuralgia. — Howe 
("Revist. Argent, de Buenos Aires" ; "Dtsch. Med.-Ztg.") has succeed- 
ed in curing with strychnine a patient who had suffered for fifteen 
years with a neuralgia that had resisted all other treatment. Four hy- 
podermic injections of the drug were given at the seat of the pain, and 
this was followed by improvement. The subsequent injections were 
thrown into the back. The treatment lasted three weeks, and the result 
is said to have been brilliant. 

Sucupira. — This seems to be the generic name of the soukoupire, a 
tall tree found in several varieties in Brazil. According to M. Cam- 
pardon ("Gaz. hebdom. de med. et de chir."), the Brazilians use the 
bark as a depurative and to mitigate the pain of rheumatism. 

Iodine and Pyridine in the Treatment of Asthma. — The alkaloid 
termed pyridine (C 5 H 6 N) is a colorless, volatile liquid, of a very pene- 
trating odor, miseible with water, and forming with the mineral acids 
salts which are very soluble but unstable. It is obtained by the dry 
distillation of various organic substances, such as Dippel's animal oil, 
certain alkaloids (including cinchonine, quinine, morphine, and atropine), 
and coal-tar. It is found also in the condensed products of tobacco- 
smoke and in nicotin itself. M. Germain See lately read an interesting 
paper before the Academie des sciences (" Rev. med.") on the use of py- 
ridine in the treatment of asthma. He declares that iodine is the great- 
est curative agent in this affection, whatever form it may take, and that 
pyridine is the best palliative for use during the attacks. It causes a 
decided and immediate diminution of the feeling of oppression, so that 
the breathing becomes calm, while the action of the heart preserves its 
regularity as well as its force. After about an hour there is in many 
cases an irresistible desire to go to sleep, but no stupor or any approach 
to anaesthesia, although the reflex excitability is diminished. The rem- 
edy should be given by inhalation, a fluidrachm or more being poured 
on to a napkin in a close room. The inhalation should be continued 
for twenty or thirty minutes, and should be repeated three times a day. 
After two or three inhalations, auscultation will show great improve- 
ment of the physical signs. A few persons seem to have their suscep- 
tibility to the action of the drug impaired at the end of a week or ten 
days, and then it is well to begin with the iodine treatment. 

Preparations of Iodoform. — The same journal quotes from the 
"Courrier medical" as follows: 

Iodoform 15 grains ; 

Glycerin 5 drachms ; 

Essence of mint 6 drops. 

Used on vaginal tampons. 

Iodoform 15 grains; 

Glycerin 75 " 

Distilled water 3 ounces. 

For injections in cases of gonorrhoea and chronic catarrh of the 
bladder. 



MISOELLAN ¥. 



28 



MISCELLANY. 



[N. Y. Mbd. Jock. 



Iodoform 15 grains; 

Sulphuric ether, 1^ 75 „ 

Olive oil, ) 
For subcutaneous injections in cases of syphilis, from half to three 
quarters of the mixture being used daily or every other day. 

Iodoform 15-30 grains; 

Potassium iodide 1 drachm ; 

Tokay wine 2£ drachms. 

For internal use, in cases of convulsions, in doses of from three to 
fifteen drops, in a glass of wine, three times a day. 

Iodoform H grain; 

Lyeopodium 6 grains ; 

Extract of phellandrium seed 15 " 

Divide into ten pills, from three to five of which are to be taken 
daily, for bronchorrhoea or emphysema. It should be borne in mind 
that the internal use of iodoform disposes to haemoptysis. 

Discs for Sick Headache. — At a recent meeting of the Societe de 
therapeutique (" Progr. med.") M. Mayet, his, stated that he had had 
discs made after the following formula : 

Menthol, ) 

Chloral hydrate, f each 7* grains ; 

Spermaceti 30 " 

Cocoa butter 15 " 

A disc is to be bound on over the seat of the pain. M. Mayet said 
that he had never observed that these discs had an irritating effect. 

Erythrina Corrallodendron as a Calmative. — Bochefontaine and 
Rey (" Annee med.") have found this plant, which is in common use in 
Brazil, where it is called mulangu or murungu, of service as a calma- 
tive and hypnotic in the agitation and sleeplessness of the insane, seven 
or eight grains of an extract being sufficient to cause sleep in such 
cases. 

The Treatment of an Acute Attack of Articular Gout. — In a re- 
cent monograph by Dr. Robson Roose (London : H. K. Lewis), the 
author says that, when called to a case of this sort, he invariably exam- 
ines the urine for albumin. If he finds none, and there is constipation 
with signs of congestion of the liver, he orders two or three grains of 
calomel, to be followed by a draught containing sulphate and carbonate 
of magnesium. If there is no marked evidence of hepatic congestion, 
milder remedies will suffice for the constipation ; the saline draught 
alone, or ten grains of pilula colocynthidis et hyoseyami, with perhaps 
a grain of calomel or a quarter of a grain of resin of podophyllum, gen- 
erally producing a free action of the bowels. At the same time he 
orders a mixture containing ten minims of wine of colchicum and from 
ten to twenty grains of some alkaline salt, such as bicarbonate of potas- 
sium or of sodium, carbonate of magnesium, or citrate of magnesium or 
potassium. This should be taken four times in the twenty-four hours, 
and continued according to circumstances. If there is much fever, two 
drachms of solution of acetate of ammonium may be added to each 
dose. The following application gives great relief from the pain : 

Extract of belladonna 2 drachms ; 

Glycerin | ounce ; 

Water 2 drachms. 

It is applied to the affected joint on cotton wool, and the part 
should be raised on a pillow and kept in a comfortable position. While 
active symptoms continue, the diet should be restricted to such articles 
as arrowroot, sago, gruel, milk puddings, etc. Seltzer, Apollinaris, or 
any other aerated alkaline water may be used freely. When the acute 
symptoms have subsided, beef-tea, fish, and chicken may be taken in 
small quantities, but the return to the usual diet should be very gradual. 
Rest and care are essential for some days after the subsidence of the 
paroxysm. Leeches, blisters, and especially cold applications, should 
be avoided. 

The Hygiene of the Lying-in Chamber. — In a recent address before 
the Medical Society of the County of Albany (" Albany Med. Annals "), 
Dr. T. K. Perry said : " I attend everything that I am called to within 
the legitimate domain of my profession, from scarlet fever to phage- 
denic erysipelas. I witness, assist in holding, and hold a fair number 



of autopsies every year, and all this time keeping right on with my ob- 
stetric work without regard. I have never ordered the paper from the 
walls of the expected lying-in chamber, nor have I ever had them sized 
with a solution of mercuric bichloride. Neither do I immerse hands or 
instruments in any disinfectant previous to or during attendance on 
these cases. I will also add that I have never in a single instance em- 
ployed intra-uterine injections at such times, contenting myself with 
simple vaginal douches ; and, notwithstanding this very great careless- 
ness and almost criminal neglect on my part, I am still able to hold up 
my hands for inspection, and find them perfectly clean, washed of even 
the stigma of misfortune. Not a death has occurred to any patient I 
ever attended during confinement, save as above reported [two deaths 
from haemorrhage and one from eclampsia] ; and, although I have 
many times witnessed chill, fever, abdominal tenderness, etc., hot water 
per vaginam, hot fomentations to the abdomen, diet, and anodynes have 
constituted and completed the treatment and cure." 

Inhalations of Oxygen for Puerperal Convulsions. — It is known, 
says Holstein ("Gaz. med. de Paris") that oxygen has the property of 
enfeebling, or, to use a fashionable term, "inhibiting," exaggerated 
reflexes. On the strength of this fact, Professor Lachkievitch, of 
Kharkow, lately proposed inhalations of oxygen in cases of puerperal 
eclampsia of reflex origin. In two consecutive cases Favre (" Wratch "), 
acting on the suggestion, has produced truly brilliant results. He is 
convinced that a bag of oxygen will soon be considered as indispensa- 
ble in lying-in hospitals and obstetrical clinics as the forceps, the cranio- 
clast, and other like instruments. 

Tannate of Mercury in the Treatment of Syphilis. — According to 
Leblond ("Gaz. hebdom. de med. et de chir."), this new preparation of 
mercury (the hydrargyrum tannicum oxydulatum of the Germans) has 
the composition Hg 2 (C 27 Hi 9 0.7)j. The simplest way of preparing it is 
by adding to a solution of mercurous nitrate a slight excess of sodium 
tannate in solution. The tannate of mercury falls in the form of a 
yellow precipitate which rapidly turns green. It is washed by deeanta- 
tion until the washings no longer precipitate on the addition of acetate 
of lead, and cease to show an acid reaction. The precipitate is then 
collected on a filter and dried in the open air. It is insoluble, and 
should be given in the form of pills, for which Casanow's formula is as 
follows : 

Tannate of mercury 45 grains ; 

Extract and powder of licorice q. s. 

Divide into sixty pills ; two to be taken twice a day, after eating. 
The salt is incompatible with alkalies, even in weak solution. 

The Action of Veratrine in Cholera Nostras. — Schulz ("Dtsch. 
med. Wchnschr." ; " Ctrlbl. f. klin. Med.") infers that the effect of this 
alkaloid in the treatment of cholera nostras is not due to its action on 
the micro-organisms, but to its inducing a temporary hyperamia of the 
intestine, whereby the resisting power of the latter is enhanced. 

Lotions for Pruritus of the Genitals. — A contributor to the " Union 
medicale " credits Doyon with the following prescriptions : 

Bichloride of mercury, ) each 4 . 

Chloride of ammonium, ) 

Almond mixture 13 ounces. 

In case this fails, use : 

Chloral hydrate 75 grains ; 

Rose-water 3 ounces ; 

Distilled water 4^ " 

After the parts have been bathed with the lotion, they are to be 
powdered with starch. 

Cocaine in the Treatment of Sore Nipples. — Herrgott (" Ann. de 
gynec." ; " Union med.") sums up his experience as follows : 1. All the 
women with sore nipples who came under observation were able to give 
suck without pain after a four-per-cent. solution of cocaine hydro- 
chlorate had been applied to the nipple. 2. The condition of the nip- 
ple was improved, and, where the cracks were not deep, they disap- 
peared rapidly. 3. Cocaine should be used whenever the nipples are 
sensitive, in order to prevent fissures, the latter being often due to a 
shrinking movement on the part of the mother whenever the child 
seizes the breast. 



THE NEW YOEK MEDICAL JOURNAL, July 11, 1885. 



Wttt xx res aitir ^irbr esses. 



LECTURES ON" 
ELECTRICITY IN MEDICINE, 

DELIVERED AT THE MEDICAL DEPARTMENT OF THE UNI- 
VERSITY OF VERMONT, BURLINGTON, 

By AMBROSE L. RANNEY, M. D., New York. 
Lecture I. 

(Continued from page 7 15.) 
THE CHOICE OF A BATTERY AND ELECTRICAL APPARATUS. 

In selecting a battery for purely medical purposes, the 
chief objects to be attained are (1) cheapness ; (2) con- 
stancy of the elements, and their accessibility for repairs, 
cleaning, etc. ; (3) durability of the elements ; (4) a sufficient 
number of elements ; (5) ease of renewal of the elements ; (6) 
ease of introduction of any number of elements into the circuit ; 
and (7) an ability to select such as may be required from 
any part of the battery. 




Fig. 26.— The Physician's Handy Cabinet Battery. — The accompanying 
cut represents a light and compact form of cabinet battery, designed by the 
author. It iH on castors, and can be wheeled about the consultation-room. 
This admits of the use of the instrument when the patient is in the gynae- 
cological chair or upon the office lounge ; or when any form of fixed appa- 
ratus, such as the laryngoscope, the inhaler or spray, etc., is being simul- 
taneously employed. In some of my later models an immovable tray is 
placed beneath the battery for electrodes, and a movable shelf is also pro- 
vided upon which a milliampere-meter, the solution of table salt, and the 
electrodes in actual use can be set. A glass cover protects the battery from 
dirt when not in use. E, faradaic coils ; K, plunger ; G, faradaic binding- 
posts ; F, interrupter ; I), drip-cup ; R, current-selector of single cells ; S, 
the same of four cells to each button ; M, coil to work the interrupter for 
the galvanic current ; L, switch to work or disconnect the interrupter (V) ; 
P, galvanic binding-posts ; 3-5 and 4-ti, connecting rods to allow of the 
action of M. The commutator lies above P. 

For the general practitioner it is necessary, as a rule, 
that a galvanic or faradaic battery shall be arranged for 



transportation ; hence the cups which hold the fluid should 
have a rubber cover, or some other device which will pre- 
clude the possibility of spilling the fluid. Again, some 
of the batteries manufactured are liable to become rapidly 
oxidized by the fumes of the battery fluid. This tends to 
destroy their durability, and to cause difficulty in keeping 
them in good working order. Finally, it is very desirable 
that portable batteries should be as light as possible, and 
not too large to be handled easily. 

The attachments upon the key-board of every portable 
galvanic battery should comprise a current-selector and a 
commutator. There should be at least four rheophores, in 
order to make allowance for breakage, additional connec- 
tions, etc. Several electrodes of different sizes and shapes 
should also be selected — preferably a large, a medium, and 
a small one — a wire brush, and an interrupting electrode. 
These can be added to as circumstances demand. 

For office purposes a cabinet battery has some decided 
advantages over a permanent one placed in an adjoining 
closet or cellar and connected, by means of wires, with a 
key-board in the consulting-room. A cabinet battery can 
be easily wheeled about, and is readily repaired. The cabi- 
net should be so arranged as to allow the back and front of 
the compartment for the cells to be removed, in case the 
battery needs repairs, or a renewal of the fluid. The con- 
nections of the battery with the key-board should also be 
made as easy of access as possible ; this decreases the ex- 
pense of alterations or repairs when such become necessary. 
They should be protected, moreover, as far as possible, 
against oxidation and dirt. 

, The cabinet battery which I use in my own office was 
made, under my special direction, by Waite & Bartlett, of 
this city, and is as nearly perfect as one could desire. It 
contains forty cells of the Leclanche pattern, which are 
equivalent to sixty of the gravity cell. The connections 
and the cells can be exposed and easily reached by remov- 
ing the front and back of the case. The accompanying cut 
represents its special features better than a verbal descrip- 
tion. Considerable expense in constructing such a battery- 
may be saved in the case, and by dispensing with some of 
the accessory apparatus shown. 

The gravity cell makes a very serviceable and durable 
permanent battery for office work. It has one advantage 
over some other cells — viz., that it has great constancy 
of action and that its activity can be renewed by the ad- 
dition of crystals of sulphate of copper to the fluid when 
necessary without disturbing the cells. For this reason the 
sulphate-of-copper cell, in some one of its various forms, 
is employed exclusively in telegraphic lines. It can not 
be transported, however, about the room to suit the con- 
venience of the patient or the physician during his ex- 
amination so well as some other cells adapted for a cabinet 
battery. It is also difficult in many cases to repair the wire 
connections of a fixed battery (running, as they often do, 
through partitions and plastered walls to reach the key- 
board) when they become inefficient from any cause, 

A permanent battery is somewhat cheaper to construct 
and takes up less room in the office than a cabinet, because no 



30 



RANNEY: LECTURES ON ELECTRICITY IN MEDICINE. 



[N. Y. Med. Jouk., 



case is required ; but, in my opinion, these two advantages 
are not sufficient to render it preferable to the other for 
office or experimental work. I have known several of my 




Fig. 27. — Large Cabinet Battery. From a photograph of one used by the author, and constructed from 
designs specially furnished by him. The current-selector and rheotome differ in several respects from 
those commonly used. The faradaic attachment has a Du Bois-Reymond coil. The milliampere-meter 
shown in the cut is that devised by Dr. Rudisch. I am at present engaged in the construction of one 
of a novel pattern, which I hope to present to the profession hereafter. The cells are of the Leclanche 
pattern. The faradaic attachment is operated by a Fuller's cell. 

medical friends to discard it (after a thorough trial) for 
a cabinet battery. If a permanent battery is deemed pref- 
erable by any of you (for reasons of your own) rather than 
a cabinet battery, be sure and place your cells on shelves in 
your office or waiting-room, and not in a cellar. The wires 
will not be so liable to corrode from dampness, and the cells 
will be constantly under your eye, so that you can see when 
they require attention. 

Respecting the selection of the cheaper forms of bat- 
teries for general medical use, it is important that accuracy 
of workmanship shall not have been sacrificed in order to 
lessen the cost. The construction of the primary and sec- 
ondary coils of a faradaic machine and the adaptability of 
the interrupter to slow and rapid breaks in the circuit should 
be looked into before a decision is reached. Poor coils and 
a bad interrupter render a faradaic machine almost worth- 
less. A "drip-cup" containing mercury, in which the zinc 
element is placed when the battery is not in use, is a desira- 
ble feature in a faradaic machine. 



Do not buy a magneto-electric machine whose motor 
power is furnished by a crank to be turned by the hand. 
It is practically useless for medical purposes when compared 
with a good faradaic instrument. 

The Grenet cell is now used by 
most of the manufacturers of electrical 
apparatus for a portable galvanic or 
faradaic battery. It is the best cell 
for many reasons. A thirty-cell gal- 
vanic battery gives all the current that 
is required by the general practitioner. 
Personally, I prefer the one made by 
Waite & Bartlett, of this city, over that 
of other manufacturers, on account of 
its modified current-selector (Fig. 23). 
It does not oxidize as do other forms 
of batteries (which have a dial current- 
selector attachment) when in constant 
use. It is also cheaper than those 
made by many other firms. Every 
galvanic battery should have a com- 
mutator on the key-board. Without 
this appliance electro-diagnosis be- 
comes difficult. 

Respecting the purchase of a static 
electric machine, it may be well to 
state that a good one is quite expen- 
sive, and is only adapted for office use. 
I am convinced that static electricity 
has some points of advantage which 
can justly be urged in its favor as a 
therapeutical agent, but it can never 
be extensively employed or take the 
place of galvanic and faradaic currents. 
Its use unquestionably creates a pro- 
found impression upon the mind and 
body of the patient. He sits upon an 
insulated stool, sees the " wheels go 
round," feels himself getting charged 
with electricity, and is made painfully 
conscious of its presence when sparks of an inch in length 
are elicited from his surface and through his clothing. 
How much of the reported benefits derived only from the 
use of this instrument are due to the mental impression so 
made upon the patient is still a problem which I have not 
solved to my satisfaction. 

The best American instrument of this kind is probably 
made by I. & H. Berge, of New York. It works well 
in all weathers, and their largest machine will produce a 
spark eight inches long. The electrodes for static electricity 
have to be made specially for its use. They must be well 
insulated by means of glass or hard rubber. Dr. W. J. 
Morton * has done much to popularize the use of static elec- 
tricity in this country. A water-motor is required to run a 
large static machine with uniformity, although it is not ab- 
solutely essential to its use in medical practice, as hand- 
power will answer all practical purposes. A single-plate 



Medical Record," April, 1881. 



July 11, 1885.] 



RAN NET: LECTURES ON ELECTRICITY IN MEDICINE. 



31 



machine is but a toy as a means of treatment of nervous neuralgia, I have found this form of electricity of great 
diseases. Sufficient quantity, as well as length of spark, value. 

is essential to the satisfactory employment of static elec- 5. In treating muscular pains and muscular rheuma- 

tism, spasm, and neuralgias, I prefer the spark to in- 
sulation. Patients who may have suffered for years 
are frequently cured in a few sittings. 

6. I prefer insulation over all other methods when 
the tonic action of static electricity is desired. Cerebral 
hyperemia and anaemia, headache, and vertigo are 
often rapidly relieved by this method. I frequently 
combine insulation with the " electric wind " (drawn 

jT IJ^'lIfjffl^lffi J.J /Jlf ifT^sliP' S| '^td II t """ t '""' liead b y means of an umbrella electrode) in 
III IDtll jflH 1 1'lilMuIVI 'i^Wjfliilla'iii:! iraJljllElllil y^>^BlillW ! li!iil 1111' I'M JraPIUF these cases, as the accumulated electricity is thus con- 
centrated toward the head. 

7. Sparks are particularly to service in treating 
numbness and cutaneous anaesthesia. I have remarked 
this effect especially in the sensory disturbances which 
frequently accompany hemiplegia of cerebral origin. 

8. Hemiplegia and paraplegia are best treated by 
means of the direct spark rather than the indirect spark. 
Sometimes quite severe shocks are required before the 
remedial effects become apparent. 

9. Wooden electrodes are preferable to those com- 
posed of metal when employed about the eye or ear, 
or when the patient is very sensitive to electric cur- 
rents. 

10. By drawing sparks from the region of weak or 

Fig. 28.— Improved Hoi/rz Static Machine (American Pattern). This form of diseased viscera, I have Sometimes noticed very apparent 
machine is the best now offered to the profession. The author is at present benefits. Pulmonary, gastric, and hepatic disorders 

are often directly affected by this agent when so ap- 
plied. I have relieved bronchitis in this way, and 
have had in some instances equally beneficial results 
in thus treating nervous dyspepsia, gastralgia, torpidity 
of the liver, etc. Some authors have reported beneficial 
effects from this agent in the treatment of phthisis. 

11. Muscular contractions can be excited by static elec- 
tricity with far less pain than by faradism or galvanism. 




engaged in devising some radical improvements upon the instrument which will 
(in his opinion) greatly enhance its practical utility and reduce its cost. 



tricity. My own machine consists of six revolving twenty- 
inch plates and three stationary plates. It works well in 
all weathers, and gives as large a quantity as any patient 
can bear. 

The following deductions express my convictions regard- 
ing the therapeutical value of static electricity, derived from 
an experience with it in quite a large number 
of cases : 

1. In certain diseased conditions I regard 
its effects as more instantaneous and satisfac- 
tory than those of galvanism or faradism. 

2. A machine so inclosed in glass as 
to prevent the action of dampness upon the 
revolving and stationary plates will work in 
all weathers, and is therefore free from the 
most serious objection which can be raised 
against franklinism. In the summer months 
the dampness of the air is liable to cause 
diffusion of the electricity generated by fric- 
tion, and thus to render its employment upon 
a patient difficult and often unsatisfactory. 

3. Quantity, as well as intensity, is re- 
quisite ; hence large plates, and several of 
them, are preferable to any of the single-plate 
machines. 

4. In the treatment of muscular pains, 
chronic muscular rheumatism, spasmodic af- 
fections, the functional nervous diseases, and 




Fig. 2!). — Drawing the Indirect Spark prom the Body op a Patient. The chain attached 
to the electrode is connected with a neighboring gas-pipe or water-faucet. This cut should be 
compared with Fig. 3. 



32 



STUB: CHOLERA ASIATIC A AND CHOLERA NOSTRAS. 



[N. Y. Med. Jocb., 



The so-called " static induced current " * is a very efficient 
way of subjecting individual muscles to the current when 




Fig. 30.— Various Forms of Electrodes Employed with a Static Machine. 
The handles are usually of glass. The author has substituted handles of 
hard rubber, which do not break easily and are equally efficient for the pur- 
pose of insulation. 

their contraction is desired. The painlessness of this method 
is a point which alone should strongly recommend it. 




Fig. 31.— Morton's Spark Electrode. The sponge-covered tips may be of 
any size «r shape. 

12. Perhaps the most phenomenal results which have 
been obtained by static electricity are achieved in the treat- 
ment of hysterical patients. Hysterical aphonia, hemianses- 
thesia, paralysis, and hystero-epilepsy have been cured by a 
few sittings, by means of insulation and sparks. 

(To be continued.) 

* First described by Dr. W. J. Morton. 



#rirjfmal Cffmmumcations. 



CHOLERA ASIATICA AND CHOLERA 
NOSTRAS ; 

THEIR DIAGNOSIS AND TREATMENT, 
WITH SPECIAL REFERENCE TO THE BAOILLUS* 
By ARNOLD STUB, M. D., 

BROOKLYN. 

Mr. President and Members of the Kings County 
Medical Society : At a meeting of the Royal Medical and 
Chirurgical Society of London, March 31, 1885, Sir Guyer 
Hunter made the remark that he had not been able to find 
a difference between cholera asiatica and cholera nostras. 
Upon reading this remark, I remembered a case which oc- 
curred in my own practice, and whose history tends to 
support the opinion of the English physician. Permit me 
to relate the case : 

Monday, July 26, 1881, a prominent gentleman, closely con- 
nected with one of the transatlantic steamship companies, was 
taken with a light diarrhoea, which continued Tuesday and 
Wednesday; a few dark-colored, painless stools and a feeling of 
being tired were not sufficient to make him call for medical aid, 
and he contented himself with taking a few drops of essence of 
ginger and some of the so-called Sun cholera mixture, which, 
however, did not relieve the disorder. After midnight, during 
the night from the 28th to the 29th, his diarrhoea increased, 
vomiting commenced, spasmodic contractions of the muscles of 
the calves of his legs and severe griping pains created consider- 
able suffering, and I was sent for. 

I found the gentleman very much prostrated. Constant vom- 
iting of a greenish fluid, profuse odorless alvine discharges of 
rice-water appearance, a cold skin, an anxious countenance, 
cold tongue, constant spasms of the muscles of the lower ex- 
tremities, and extreme prostration marked the case. I ordered 
at once sinapisms to various parts of the body, alternately ap- 
plied, and brushing of the skin with diluted alcohol. Internally 
I prescribed a mixture consisting of 
01. cajeputi, -| 

01. cinnamomi, \ aa gtt. xii; 

01. menth. pip., J 

Sp. vini gallici ^ j ; 

Mist, potass, citrat usque ad. § vj. 

M. S. One tablespoonful every half-hour until vomiting 
ceases. 

I also ordered 

Mass. hydrarg gr. xx ; 

Pulv. opii gr. viij. 

M. ft. massa in pil. No. 8 divid. S. One pill every two hours. 
Ice in small pieces to relieve thirst, hot flat-irons to the 
soles of the feet, and heated flannels to the abdomen, in num- 
berless other cases, had not failed to give the desired relief, and 
when I called again, a few hours afterward, I expected to find 
a change for the better. However, I was sadly disappointed, 
and the patient remained in the same condition until next day. 

On the morning of the 30th I found all the symptoms in- 
creased — the vomiting and purging were almost constant, the 
skin was cold and clammy, and the hands had the characteristic 
appearance of those of a washerwoman. If I lifted a fold of 

* Read before the Medical Society of the County of Kings, May 
19, 1885. 



July 11, 1885.] 



STUB: CHOLERA ASIATIC A AND CHOLERA NOSTRAS. 



33 



the skin from any part of the hody, it remained standing in the 
same position for some time. The eyes were suuken, and the 
nose looked pinched. The whole face had an anxious and dusky 
look, the tongue was as if paralyzed, the voice was almost in- 
audible, the lips were blue, and the radial pulse could not be 
felt. The vomited matter as well as the rice-water discharges 
was strongly alkaline, and changed litmus-paper from red to blue. 
The urine was suppressed. I ordered at once a hot bath, and 
continued treatment; also ordered bags filled with hot bran to 
the lumbar region. To allay the excessive thirst, I ordered the 
ice to be continued. I also prescribed iced champagne and 
brandy. 

August 1st, the patient became still lower. The tongue and 
skin were of a reptile-like coldness. A few drops of urine, drawn 
with a catheter, coagulated immediately upon being heated in a 
test-tube. Ordered one ounce of Tokay wine hourly per rectum, 
because champagne or brandy was not retained by the stomach. 
Directed another hot bath to be given, and called Dr. Hesse, 
formerly of this city, in consultation. 

We both came to the conclusion to try musk and camphor, 
aa gr. ij, every two hours; ordered oatmeal gruel and Tokay 
wine per rectum every two hours; repeated the hath in a few 
hours; and continued the friction of the skin. Hot bran bags 
were constantly applied to the lumbar region. 

The first of the powders the patient vomited at once; the 
second, given immediately afterward, he retained. Sometimes 
his stomach rejected the champagne, when we alternated the 
latter with iced brandy. 

The following day we added strong black coffee to the 
stimulants prescribed, and continued this treatment until the 
eighth day of his illness, when his skin gradually became of natu- 
ral warmth, his pulse noticeably of greater volume, his stomach 
less irritable, his mind less confused, and his speech more audible. 

During this time he had taken every twenty-four hours one 
bottle of Tokay wine, with oatmeal gruel, per rectum; one 
bottle of champagne and a considerable quantity of brandy by 
the mouth. The urine was entirely suppressed for three days, 
when it returned, and became gradually less albuminous. 

After the eighth day we commenced to feed with clam- 
broth, beef-tea, etc., and continued champagne and brandy ac- 
cording to circumstances. Prostration still remained. 

About the ninth day well-marked typhoid symptoms devel- 
oped, with a range of temperature of 102° in the morning and 
104° in the evening. 

At the end of the second week he complained of an intol- 
erable itching, particularly in the face, and, in spite of all efforts 
to prevent him, he would scratch until the blood trickled down 
his face. I may remark here that no opiates had been given him 
for over a week. During the whole time he had been kept in 
a horizontal position, and even a change of garments was effect- 
ed in that position. The itching lasted for about twenty-four 
hours, when all at once a furunculosis commenced, particularly 
attacking the face. Some of the boils were very tardy in heal- 
ing, and had an almost gangrenous appearance in the center. 
The whole illness lasted five weeks, when I considered the gen- 
tleman sufficiently strong to be removed to the Catskills. 

Dr. Hesse, as well as myself, came to the conclusion that 
this was a case identical with Asiatic cholera, although we 
did not feel ourselves justified in calling it by that name, 
because no other case of such a nature had appeared in the 
city. We were at a loss to find symptoms for a differential 
diagnosis between cholera nostras and cholera asiatica, ex- 
cept from the circumstance that no epidemic cholera existed 
in this country or in Europe. 



I may add that from the time I made my first call I or- 
dered disinfectants in the form of chloride of lime and car- 
bolic acid to be used in the sick-room as well as all over the 
house, and restricted the attendance upon the patient to as 
few persons as possible, who avoided intercourse with the 
rest of the family. 

During the year 1868 or 1869 I was called upon to 
see a case of sporadic cholera in consultation with the late 
Dr. Barthelmess. The patient lived in Boerurn Place. 
When I saw him the disease was in the algid stage, and all 
I am able to remember about it is, that he died the same 
day, which was the third day of his illness. 

During the summer of 1866 I had spent a whole night 
at a boarding-house in Flatbush, whose inmates had been 
taken down with cholera asiatica. Myself and the husband 
of one of the victims were the only persons who left the 
house alive next morning. 

I was called upon to attend the wife of this gentleman, 
and found a whole house full of dead and dying without a 
single attendant. If Dr. Conklin, who was health officer at 
that time, happens to be present, he will perhaps be able 
to refresh my memory by telling us how many people died 
in that house that night. 

Gentlemen, I have a very vivid recollection of that ter- 
rible night and of those cases, and I assure you that I am 
not able to draw a line of distinction between the cases seen 
in 1 866 at Flatbush, in the boarding-house kept by the keeper 
of the Penitentiary, from whence the disease had been 
communicated to the inmates of the boarding-house, and 
those cases of sporadic cholera which I have seen since, in 
1868 or 1869, and in 1881. 

The question naturally presents itself to my mind, Are 
the views of Sir Guyer Hunter correct, and is there actually 
no line of distinction between cholera nostras and cholera 
asiatica, when the first case or cases of the latter appear in 
a community like ours? I must answer this question in 
the negative as long as we take the complex of symptoms 
into consideration only. 

But, gentlemen, within the last year or two investiga- 
tions have been made into the aetiology of Asiatic cholera 
which bring us a step farther toward distinguishing between 
the two diseases above mentioned. 

When 1 first became acquainted with the labors of Dr. 
Koch, and read of his discovery of the comma bacillus, I 
was enthusiastic in the belief that at last we had found the 
real cause of Asiatic cholera, and, by a simple microscopical 
investigation, would be able to diagnosticate cholera asiatica 
from cholera nostras. 

But, gentlemen, here I was doomed to be disappointed. 
Then, immediately afterward, Dr. Prior and Dr. Finkler pub- 
lished the result of their investigations, and proved, or at 
least attempted to prove, that the comma bacillus might 
also be found in cholera nostras. 

Dr. Deneke found the curved bacillus in old cheese, Dr. 
Lewis found it in sputa, and last, but by no means least, 
Emmerich declared that the comma bacillus was not the 
cause of cholera, but that a bacterium, discovered by him 
in Naples, alone was the whole source of the disorder. 

After I became acquainted with the foregoing state- 



34 



STUB: CHOLERA ASIATIC A 



AND CHOLERA NOSTRAS. 



[N. Y. Med. Jode., 



ments I immediately began to investigate, and spoiled about 
a large boxful of covering glasses in tbe attempt to find the 
comma bacillus in sputa, in old cheese, in the discharges of 
cholera nostras, in chicken cholera, and in the discharges of 
typhoid-fever patients. 

I certainly did find curved bacilli in every one of the 
specimens, but I did not find the characteristic spirillum 
which I found in the preparations sent me by Dr. Nicati, 
of Marseilles, and -those I received afterward through Mr. 
Emmerich and Mr. McAllister, of New York, procured from 
microscopical laboratories in Berlin and Brussels, and rep- 
resenting comma bacilli artificially cultivated. 

Although the curved bacilli found in cholera nostras and 
in old cheese are also spirilla, they are of a different size and 
have less of the corkscrew shape than the comma bacilli. 
After the former have been prepared for the cover glass and 
put up in balsam for examination, they assume partly the 
form of the cholera bacillus ; but even in this condition they 
are larger than the latter. But if a suspended drop from 
the rice-water stools of a cholera-nostras patient and one 
from the stools of a patient suffering from Asiatic cholera 
are examined alongside of each other, a difference in the 
size and shape of the spirilla will become easily apparent. 
The spirillum of Asiatic cholera is only to be mistaken for 
that of recurrent fever, and Koch himself declares that he 
could not distinguish one species from the other if placed 
alongside of each other. 

Gentlemen, I believe that Koch is correct in reference to 
his views of the aetiology of cholera and in regard to the 
bacillus question. And the reason why I think so I shall 
state later on. 

Starting from this base, let me suppose that the cholera 
raging in Spain at the present time assumes wider propor- 
tions ; it spreads again to France ; it reaches Germany and 
invades England. Steamers bring us within ten or twelve 
days in direct communication with ports which may be vis- 
ited by cholera patients at any time. One of the latter may 
get on board of the steamer ; he may be well at the time 
he enters the steamer ; he may be taken with a diarrhoea 
during the time he is on board. According to authors, the 
time of incubation may vary from one to fourteen days, and, 
if this is correct, a man may travel from Marseilles to Liver- 
pool or London, and from London to New York, without 
having the slightest symptoms of cholera before he lands 
here, or he may have diarrhoea which may pass unnoticed 
by him and others ; but this man, although he may never 
himself develop the second stage of cholera, may deposit 
upon the steamer, or perhaps afterward in this city, the 
germ which will, in a few days, infect the whole city with 
the pestilence, and we may never find out where it came 
from. 

Now, gentlemen, let me suppose that such conditions 
prevail this coming summer; we have learned that the chol- 
era is in France, perhaps in Germany, but not in England. 
The English steamers, consequently, are not subjected to 
quarantine. All rags have been carefully excluded from land- 
ing upon these shores, although I never heard that rags 
had carried the disease, provided they were not wet. And 
I am called, perhaps after midnight — which, by the way, 



seems to be the time such cases first become most trouble- 
some — to see a patient who suffers from symptoms of chol- 
era. The question naturally arises, Have I to deal with a 
case of cholera morbus or cholera asiatica ? The question is 
an important one. Shall I notify the Board of Health, and 
perhaps unnecessarily alarm the community ? Shall I isolate 
the patient, or shall I let matters go on, wait for develop- 
ments, and jeopardize the lives of other people ? In order 
to come to a proper diagnosis of the case, I proceed at 
once to look for the cholera bacillus in the rice-water dis- 
charges. In three different ways this object may be at- 
tained. I take two covering glasses, clean them well, after 
the most approved method, in nitric acid, wash them in 
alcohol and in ether, and afterward in distilled water. 

As soon as they are dry I place a drop of the rice-water 
discharges upon one of those glasses with a spatula, pre- 
viously sterilized by heating it over an alcohol-flame or a 
Bunsen burner, and spread the drop of the rice-water dis- 
charge carefully out upon the covering glass. I place the 
second glass upon the first and draw them asunder, in order 
to cause an even and uniform spread of the material upon 
both glasses. 

As soon as they are completely dried, which will be in 
a few minutes, I draw them slowly three times through the 
flame of an alcohol-lamp, holding them with a pair of for- 
ceps covered side upward. Then I take them home and 
heat in a test-tube a small portion of a watery solution of 
gentian violet or fuchsin. As soon as the fluid begins to 
smoke, I pour some of it into a watch-glass, and, taking the 
covering glasses between two fingers, I let them drop upon 
the fluid with the side containing the suspected material 
downward. I let them swim for about ten minutes, take 
them from the fluid, wash them in sixty-per-cent. alcohol 
for about two minutes, remove the water by dipping them 
for a few seconds into absolute alcohol, wait a few minutes 
longer until they are dry, and then examine them under 
the microscope with a power of water immersion, or, 
better still, with ^ oil immersion, and expect, of course, 
to be able to diagnosticate, from what I see, true Asiatic 
cholera or cholera morbus. 

But, gentlemen, although the method above described 
is exactly the one used by Koch to bring the comma bacilli 
into view, if the material is taken directly from the patient, 
or if taken from an artificial cultivation, I may be sadly disap- 
pointed in all probability, because, in the first place, I may 
find no characteristic spirilla, and those bacilli we do find 
may belong, as far as their microscopical appearances show, 
just as well to cholera morbus ; or I may find only straight, 
rod-like bacteria mixed with a few curved ones, such as 
can be seen in all the excrements of ordinary diarrhoea; 
because it is a well-established fact, I think, that in the be- 
ginning of Asiatic cholera the characteristic spirillum can 
not be immediately recognized under the microscope. A 
better method, however, would be to place a drop of rice- 
water discharge upon a covering glass, and put the latter, 
with the drop of fluid downward, upon a shallow glass cell ; 
if this suspended drop, which may be stained with one of 
the basic aniline colors, is examined with a powerful immer- 
sion lens, it is possible that we may find sufficient evidence 



July 11, 1885.] 



STUB: CHOLERA ASTATIC A AND CHOLERA NOSTRAS. 



35 



to base a diagnosis upon. We shall see at least a large 
quantity of bacteria alive, and, if the fluid contains a suffi- 
cient quantify of the cholera bacilli, they will appear like 
a swarm, of mosquitoes moving hither and thither, and 
among those there will be noticed occasionally a few spirilla 
of a wave-like form. So, at least, does Koch describe the 
microscopical appearance of a suspended drop of artificial 
beef-tea cultivation, and there is no doubt that the same 
may be observed if rice-water discharges are used for ex- 
amination from a patient who has been sick for some time, 
but it is very doubtful if we shall be able to gain this result 
in the earliest stage of cholera. 

Another method of distinguishing the cholera bacilli is 
published in the " Deutsche medicinische Wochenschrift," 
Berlin, April 2, 1885. Professor Max Schottelius, of Frei- 
burg, went to Italy to study the cholera, and, being ad- 
mitted into a cholera hospital of Turin, he made numer- 
ous investigations. The principal result he obtained is 
the following: He mixed 100 to 200 c. cm. of the sus- 
pected faecal matter, or rather rice-water discharge, with 
250 to 500 c. cm. of slightly alkaline meat-broth. This 
mixture must be shaken and put into a high beaker-glass. 
The glass must be put in a warm place, the temperature 
of which does not exceed 40° C, or 104° F. The fiuid 
remains standing for from ten to twelve hours. After this 
time the surface of the fluid is touched with a ijlass rod, and 
a drop placed upon a covering glass; further preparation, 
and staining with a concentrated watery solution of fuch- 
sin, as described before, will, under the microscope with a 
power of about 600 diameters, show almost a pure cultivation 
of the comma bacillus, if the case has been genuine cholera. 
Examination of a suspended drop of this mixture gives also 
a characteristic and perhaps still better demonstration. The 
surest method, however, suitable for diagnostic purposes, will 
be the cultivation with nutritive gelatin upon glass plates, 
and we shall find it of sufficient simplicity to make practical 
use of it, provided we are able to obtain at short notice the 
necessary nutritive gelatin of slight alkaline reaction. I 
herewith will mention briefly two formulae found to be most 
efficient for use: First, 17 ounces of good, finely chopped 
meat, added to 34 fluidounces of distilled water, and well 
stirred, remains standing in the ice-box for twenty-four 
hours. Afterward the whole is strained through gauze by 
means of a press, and sufficient distilled water added to 
make again 34 ounces. To this must be added '2\ drachms 
of table-salt, and from 1^ ounce to 3 ounces of the purest gela- 
tin ; allow the whole to dissolve by gentle heat, neutralize 
with carbonate of sodium, and add a little of the latter in ex- 
cess to give the mass a weak alkaline reaction, sufficient to 
turn red litmus-paper slightly blue. The neutralized solu- 
tion must be boiled for an hour upon a water-bath and, still 
hot, filtered through paper. The filtrate, boiled again and 
afterward put upon ice, must be clear and transparent. Dur- 
ing the boiling process a turbidity, caused by phosphates, 
may appear, which, however, will disappear as soon as the 
gelatin has been cooled upon ice. 

Another process, described by Dr. F. Hucppe, professor 
of hygiene and bacteriology at the laboratory of Fresenius, 
of Wiesbaden, is the following : Peptone, 3 p. c. ; grape-sugar, 



0 - 5 p. c. ; extract of meat, 0 - 5 p. c. and from 5 to 10 p. c. 
gelatin. I will not try your patience by giving the whole 
process necessary for this preparation. It will be sufficient 
I think, if I mention that a little apparatus is required and 
a great deal of exactness and time. We, as practical physi- 
cians, may have the former, but hardly the latter, at our 
command, consequently I would like to take the liberty of 
suggesting that Dr. Squibb, for instance, take the matter in 
hand and prepare for us the gelatin, or that the Board 
of Health establish a laboratory where not only shall the 
gelatin be prepared, but, under the supervision of a compe- 
tent medical man, such investigations carried out as I have 
already suggested or shall hereafter describe. 

Supposing we are in possession of the necessary gelatin 
and desire to make the cultivation as above mentioned. For 
this purpose we take an object-glass, according to the size 
of the stage of our microscope, to enable us to examine the 
same afterward in all directions with a lens. We put some 
of the nutritive gelatin into a test-tube and warm it in hot 
water until the gelatin becomes fluid ; then, by means of a 
pipette, we carefully transfer some of the gelatin to the ob- 
ject-glass. 

The portion of gelatin transferred must be a few milli- 
metres thick and no part touch the edge of the object-glass. 
Then we take, with a sterilized platinum-wire, a drop from 
the rice-water discharges, and inoculate the gelatin by 
making a few strokes upon it of not sufficient depth to 
reach the glass below the gelatin. 

The longer our object-glass, the more strokes we shall be 
able to make, and the easier it will be to recognize and dif- 
ferentiate the colonies of bacteria which will grow there. 
After the gelatin has been inoculated, the plate of glass 
must be placed under a bell-glass whose walls are dampened 
inside with distilled water. This, however, is not absolutely 
necessary. Eighteen hours afterward we shall observe the 
result of the inoculation by the growth of the different spe- 
cies of bacilli. In case of Asiatic cholera we shall observe 
in the early stages of the growth a small, pale drop, not of a 
perfectly circular appearance, such as almost all other colo- 
nies of bacteria present, but with irregular, rough edges. 
From the very beginning of its growth it has a granu- 
lated appearance. A few hours after the first appearance 
of these drops upon the gelatin the granulation appears 
more marked, and looks like a mass of irregular-shaped, 
highly refractive granules, which Koch compares to a lit- 
tle pile of small pieces of glass. Within twenty -four hours 
the gelatin becomes fluid in the immediate neighborhood of 
the colony, and the latter sinks deeper into the gelatin. A 
small funnel-shaped impression is formed, in the midst of 
which the colony may be seen as a small whitish spot or 
dot. Forthe purpose of making these observations, the -lass 
plate must be placed under a microscope and examined 
with a power of about eighty diameters. In order to make 
these cultivations, a temperature not lower than 68° F. is 
necessary, which during the summer months will be easy to 
reach. In case we have to deal with a cultivation of the 
bacilli of cholera nostras discovered by Finkler and Prior, 
we shall find discs of a regular, even shape, and within thirty 
hours a funnel of 1 cm. in diameter will have formed, which 



3(3 



BURKE: FRACTURE OF THE SKULL. 



[N. Y. Med. Joub., 



in two or three days will have widened out to such an ex- 
tent that the whole of the gelatin will have flowed off from 
the object-glass. 

(To be concluded.) 



A CASE OF COMMINUTED AND DEPRESSED 
FRACTURE OF THE SKULL; TREPHIN- 
ING; FUNGUS DUR^E MATRIS; RECOV- 
ERY.* 

By W. C. BURKE, Jr., M. D., 

SOUTH NORWALK, CONN. 

0. R., aged eleven, was struck by a locomotive attached to 
an express-train, running at a high rate of speed, on the after- 
noon of November 6, 1883. 

He sustained a compound comminuted and depressed frac- 
ture of the left temporal bone, involving slightly the frontal and 
parietal bones of the same side. The blow was given while the 
boy was in the act of jumping from a car directly in front of 
the approaching train, which he did not see. He was thrown a 
considerable distance to the side of the track, and, when picked 
up, was unconscious, breathing stertorously, and bleeding pro- 
fusely from the divided temporal artery. He was taken to the 
accident-room at the station, and seen by me within ten minutes 
after the accident. At this time the pulse was very feeble and 
slow ; breathing stertorous ; pupils moderately but unequally di- 
lated, the right more than the left. The wound was cleansed, 
the bleeding vessels were secured, a temporary dressing was put 
on, and he was conveyed to his home a mile distant. He had 
lost a good deal of blood. 

An hour later, with the assistance of Dr. J. G. Gregory, I 
removed the dressings, and, enlarging the opening in the scalp, 
found that the skull had been fractured and depressed over an 
area two inches by two and a half, located a little above and in 
front of the left ear. The fractures did not extend beyond this 
oval in any direction. I found nearly all the pieces of bone 
lying loose in the wound, and they were easily removed. After 
removing all the fragments in sight and carefully cleansing the 
exposed membranes, I found a gaping wound of the membranes 
and brain substance. Gently insinuating my little finger into 
this opening, at the depth of an inch and a half from the surface 
of the skull, I felt two pieces of bone, which I cautiously re- 
moved, carrying the slender forceps along my finger as a guide. 
They proved to be fragments of the internal table of the skull 
turned edgewise and in their long diameter, evidently shot into 
the brain by the blow, like flying glass. These increased the 
depth of the wound by nearly an inch, making the wound of 
the brain about two inches and a half deep. The direction was 
obliquely downward and backward toward the pons Varolii. 
Considerable haemorrhage from the brain substance was con- 
trolled after some delay. Two vessels in the external wound 
required ligatures. 

Just as I was withdrawing the last fragment from the 
wound the patient gave the first symptom of returning con- 
sciousness. He groaned and turned his head partially to the 
left. After careful cleansing of the membranes they were 
smoothed out, everything being left in as natural a condition as 
possible, and the external wound was closed by fourteen inter- 
rupted sutures. 

A compress, wet in a five-per-cent. solution of carbolic acid 
and secured by a roller bandage, completed the dressing. These 
dressings were to be moistened repeatedly during the night 
with the solution. He rallied well from the shock, but passed 
a restless night, tossing about a good deal. Sixty-nine hours 

* Read before the Brooklyn Pathological Society, February 12, 1886. 



after the accident he uttered his first coherent sentence, al- 
though he had spoken detached words twenty-four hours pre- 
vious. Everything progressed favorably, the wound apparently 
healing well. On the sixth day I removed a part of the stitches, 
and the remainder on the seventh. When union had taken 
place throughout, except at the point of exit of the two liga- 
tures, a piece of rubber tissue was laid next the wound, and 
over this several layers of gauze secured by the roller. The 
next day the dressings were not disturbed. On the ninth the 
boy complained of a pain in the wound, and the dressings 
bulged at the seat of injury. On removal, a cauliflower-like 
growth, protruding three eighths of an inch above surrounding 
scalp, had reopened the wound to the extent of the opening in 
the skull-bone. The edges were everted so that its diameter was 
a little over three inches. In the afternoon of the same day I 
attempted to remove a portion with the galvano-cautery, but 
with only partial success. Several things were tried in the next 
day or two, but were of no avail. 

The growth by this time had increased to formidable pro- 
portions. I then determined to try the dried sulphate of zinc 
upon it. So I put on a free coating of this, and over it a com- 
press and bandage, drawn as tight as the patient would allow, 
which was not nearly so firm as I should have preferred, as he 
complained that it gave him "a feeling in his head of bursting." 

This dressing was allowed to remain forty-eight hours, when, 
on removal, I was pleased to find a slough, three eighths of an 
inch thick, easily removed. Another coating of the zinc was 
put on and similarly dressed, remaining forty-eight hours. This 
process was continued until all the diseased tissue had been 
removed down to the level of the healthy brain substance, when 
the zinc was discontinued and iodoform substituted. When the 
dressings were again removed, healthy granulations had sprung 
up all over the wound, and the process of repair went on as 
rapidly as could be desired. The constitutional treatment had 
been with iron and quinine — in short, supportive. 

At no time had the temperature been above 101° F., and 
that only once, during the first forty-eight hours. A slight 
amount of brain substance had been lost. He was discharged, 
January 25th, two months and nineteen days after the accident. 

A recovery from so frightful an accident is rare when 
we consider the extent of injury to the brain substance, the 
wound extending well toward a region of the cerebrum 
usually considered vital. And the recovery from fungus 
durse matris was hardly less remarkable. There were, I be- 
lieve, fifty-one cases of this disease following wounds of the 
brain during the late war, in which forty-five of the patients 
died, only 1*13 per cent, recovering. The boy is in perfect 
health now, and has no headache or other unpleasant symp- 
toms. Mentally, no special change is noticeable ; but his 
teacher thinks he does not commit to memory with quite so 
great facility as before the accident. But even this is doubt- 
ful. 



ON THE ERADICATION OF SYPHILIS DUR- 
ING THE FIRST STAGE BY SURGICAL 
MEANS* 

By A. H. P. LEUF, M. D., Brooklyn, 

PATHOLOGIST TO ST. MARY'S GENERAL HOSPITAL, TO ST. MART'S FEMALE HOS- 
PITAL, AND TO THE HOSPITAL FOR NERVOUS AND MENTAL DISEASE, ETC. 

Inasmuch as it was originally planned that this paper 
should not appear till the end of this year or the beginning 

* Read before the Medical Society of the County of Kings, May 19, 
1885. 



July 11, 1885.J 



LEUF: THE EARLY ERADICATION OF SYPHILIS. 



37 



of the next, I am enabled to give but an outline of what it 
is ray intention ultimately to say upon this subject. Being 
but the outline of an argument in favor of a specific thera- 
peutic measure, it will uecessarily be very brief. For the 
purpose of economizing time, I will purposely avoid refer- 
ence to authors and the discussion of the various views held 
upon this interesting and intricate question. Various, how- 
ever, as are these views, and great as may be the intricacy 
of this subject, it is yet possible to reduce them to simpler 
proportions for convenience of analytical study and syn- 
thetical deduction. My plan, therefore, this evening, will 
be to submit to you only that way of viewing this question 
which accords with my argument, and the digressions there- 
from shall be as limited as possible for the purpose of sav- 
ing time. 

Syphilis is a constitutional disease and contagious in the 
true sense of the word ; that is, communicable only by con- 
tact, and therefore produced invariably by inoculation — ex- 
cept it occasionally be autogenetic. It is preceded by a 
period of incubation, and manifests itself in three periods — 
primary, secondary, tertiary. 

The primary stage consists in the formation, growth, and 
decadence of a highlv characteristic sore at the seat of in- 
oculation after an average incubation of much longer dura- 
tion than precedes any other sore with which it might be 
confounded. A variable time after the formation of this 
sore, or chancre, the nearest set of [lymphatic glands be- 
come enlarged. 

The secondary stage is ushered in by acute characteristic 
general signs and symptoms after a definite interval, meas- 
ured by weeks, succeeding the appearance of the chancre. 
This continues for a variable time, to be followed by a period 
of quiescence, usually measured by months. 

The tertiary stage exhibits itself in the form of special 
pathological changes in one or a number of places, and either 
in one or a number of tissues, at the same time or at differ- 
ent times. These manifestations are mostly dependent upon 
their location for their greatest significance. Thus, a nodu- 
lar enlargement of the tibia is in itself harmless ; long radii 
of the calvaria perhaps the same, but for the proximity of 
a vital organ ; an exostosis within the lower part of the 
spinal canal, although similar in character, is not now so 
harmless, but, if sufficiently large, will induce paralysis of 
the parts below ; the same projecting from the walls sur- 
rounding the medulla has a significance that is fatal ; even 
in this latter instance the effect may be nil so long as the 
growth does not continue beyond a certain size. This is the 
general character of tertiary manifestations. A carcinoma 
of the breast will kill by its virulence and not by its increase 
in size, while the converse is essentially true of syphilitic 
formations. 

Thus we understand that the existence of syphilis is a 
constant menace to the body it inhabits. Of the nature of 
its active principle nothing definite is known. One fact is 
quite universally admitted, and that is, that, when inocula- 
tion has once taken place and the chancre is formed, second- 
ary symptom^ demonstrating systemic infection are inevi- 
table, and so, as a rule, are tertiary manifestations in the 
majority of cases. 



As rational therapeutics preponderates over empiricism, 
it becomes more evident that aetiological data increase in 
value for the treatment of disease. A thorough comprehen- 
sion of these is impossible without an exact knowledge of 
the minute pathological changes that accompany disordered 
states of the body. In syphilis we have no knowledge of 
the character of the virus itself. Its manifestations are 
known to us both macroscopically and microscopically, the 
latter especially in the tertiary forms. The changes it in- 
duces at the beginning, in the formation of the primary 
lesion, are not so well understood nor so generally ac- 
cepted. 

To adopt a rational plan for the interception of this 
poison previous to its geueral invasion of the body, the fol- 
lowing questions must be answered : 

1. Does the disease arise de novo — is it autogenetic ? 

2. What are the necessary conditions for inoculation ? 

3. What is the effect of the virus at the seat of inocu- 
lation ? 

4. Is there a decided interval between local and sys- 
temic manifestations? 

5. By what channels does the disease enter the system 

by the blood or by the lymphatics ? 

6. Can the progress of the virus be traced from the time 
and place of its entrance into the tissues until general in- 
fection has occurred ? 

That all this can be done I shall now proceed to demon- 
strate : 

1. Does the disease arise de novo — is it autogenetic ? 
Syphilis must have originated at some period, and at 

not so remote a day but that the circumstances existing at 
that time to favor its production must also exist at the pres- 
ent day. Therefore I can not deny the possibility of its 
occasional spontaneous origin, although compelled to admit 
that it must be a comparatively rare occurrence. 

2. What are the necessary conditions for inoculation? 
These consist in the presence of the virus and stable 

living cells in direct contact. The cutis being composed 
of dead, and to some extent desiccated, cells, it is evident 
that inoculation can not take place through it. Observation 
demonstrates that this is true, for the rule is, in carefully 
studied cases, that a denudation of the cutis vera is a con- 
stant and necessary precursor of the chancre. I will relate 
an incident in point : 

Two medical students, at a Western university, spent a 
night together in the same bed with a woman of obtuse 
morals. Neither student had had any sexual congress for 
several months preceding this night, nor did they during a 
long period subsequent. One developed a chancre, and, 
later, secondary symptoms ; the other never suffered the 
least local or general disturbance. Circumstances would 
not warrant the supposition that the chancre developed de 
novo. On the other hand, it would be contrary to clinical 
observation and the result of scientific experimentation to 
suppose that the more fortunate student escaped because he 
enjoyed a special immunity, for he had never had syphilis. 
The correct solution of the problem lies in the assumption 
that the one affected had abraded a portion of the mucous 
membrane of his penis while the other had not, and this 



38 



LEUF: THE EARLY ERADICATION OF SYPHILIS. 



[N. Y. Med. Jodb., 



was actually the case. This is not a lone instance ; there 
are many others. 

The denudation of the cutis vera — an abrasion, in other 
words — is, therefore, necessary for the introduction of syphi- 
lis through the skin or mucous membrane ; that is, direct 
contact between the virus and the stable living cells. 

3. What is the effect of the virus at the seat of inocula- 
tion ? 

It gradually, but inevitably, induces circum scribed tissue 
changes of a special character, which become evident only 
after a lapse of time varying from a little more than a week 
to more than two months. The tissue changes consist 
mainly of a proliferation of the vessel-walls and immediate 
fixed cells, without the usual amount of serous effusion and 
byperaemia. They manifest themselves in the form of an 
elevated ulceroid, with a hard base, and having a serous 
rather than a purulent discharge. The variation in the 
time at which the initial lesion appears after inoculation is 
due more, if not entirely, to its location with reference to 
the lymphatic vessels than to various grades of suscepti- 
bility by some supposed to exist in the individual. This is 
also especially true as regards the length of the interval be- 
tween the appearance of the chancre and the onset of sec- 
ondary symptoms. 

4. Is there a decided interval between local and systemic 
infections ? 

An affirmative answer to this question will be gainsaid 
by no one. An intermediate manifestation, however, is ap- 
parent between these local and general disturbances, and it 
shows itself in the first set of lymphatic glands reached by 
the lymphatic vessels beginning at the seat of inoculation. 
The time at which these glands show evidence of participa- 
tion in the syphilitic process varies. Enlargement may 
commence shortly after the formation of the primary lesion 
or within a brief period Before the onset of general second- 
ary symptoms. There can be no doubt, though, about there 
being a distinct interval between local and general infection. 
The action of the lymphatic glands leads to the next ques- 
tion. 

5. By what channels does the disease enter the system — 
by the blood or by the lymphatics ? 

By the blood ? — When we consider the rapidity with 
which the blood flows through our bodies, and the uniform 
results obtained in producing rapid effects by intra-san- 
guineous injections, it is impossible to reconcile these well- 
established facts with the comparative exceeding slowness 
of general syphilitic infection, unless it be on one ground. 
This would be that a second incubation takes place in the 
blood analogous to that at the point of inoculation, or that 
the period of incubation of the virus in the blood is longer 
than that among the stable cells; but this would be con- 
trary to all known physiologic laws and processes. Were 
the blood-vessels and their contents the distributing chan- 
nels of this poison, the general infection of the patient 
would not be so long in taking effect, nor would it be inter- 
rupted. The blood is not the channel by which the virus 
enters the system. 

By the lymphatics? — We all know, from the results of 
investigation in the physiological and pathological labora- 



tories, as well as clinical experience, that the blood is the 
body's distributer of food and air in its passage from the 
heart, while on its return it renovates the tissues by the ab- 
straction of those impurities that are the natural result of 
physiological metamorphosis. The lymphatics, on the con- 
trary, among other things, perform an interceptive function 
in preventing or retarding the entrance into the circulating 
blood of those deleterious substances for the elimination of 
which there appears to be no special provision. Thus, al- 
though carbonic oxide and urea arc very poisonous, they 
enter the blood to be promptly excreted, the one by the 
lungs and the other by the kidneys ; there is a special pro- 
vision for their elimination, as they are a normal, constant, 
and necessary product. Contrariwise, the virus of carcino- 
ma is not the outcome of normal, constant, and necessary 
physiological activity, but the result of changes that are ab- 
normal, inconstant, and decidedly unnecessary, and hence 
has not provided for it a special and normal eliminative or- 
gan. If it once enters the blood, it will remain and spread 
disaster. It only gets there insidiously. The blood does 
not take it up. Lymphatic vessels which ramify through- 
out the body and lymph-spaces existing in nearly all the 
tissues absorb this product of unusual and abnormal meta- 
morphosis and conduct it to the first set of lymphatic 
glands. Here it is retained as long as the gland is capable 
of holding it, and, when this retentive function becomes in- 
efficient, the poison passes into the blood, and the general 
infection of the individual is the immediate and inevitable 
result. 

It is through the lymphatics, then, that syphilis enters 
the system, although retarded in its progress through the 
glands. \ 

6. Can the progress of the virus be traced from the time 
and place of entrance into the tissues until general infection 
has occurred? 

This is possible, and it occurs in the following way : 

As soon as the poison comes in contact with the living 
cells it sets up an irritative process, which, in consequence 
of its persistence and special qualities, eventuates in the pe- 
culiar cell proliferation that gives rise to the initial lesion 
of syphilis. This cell formation is peculiar in that it in- 
volves the vessel-walls, causing them to grow eccentrically 
as well as concentrically, thus giving rise to an increase in 
their external diameter coincident with a diminution of cali- 
ber. Many detached cells and nuclei are to be found within 
the lumen of the capillaries obstructing the flow of blood. 
The immediate fixed connective-tissue cells also participate 
in the proliferating process, and to such an extent that the 
intercapillary spaces become packed with these new forma- 
tions. In consequence of the diminished caliber of the 
vessels, there is an absence of the degree of hyperemia so 
common in pathological cell formations. Serous effusion is 
also lacking on account of the scanty blood-supply and the 
thickening of the vascular walls. Those compacted cells 
which are on and nearest the surface, being enabled to im- 
bibe their nourishment from all directions except one, die 
and fall off from this side — that is, die at the surface. Con- 
siderable pressure is exerted within this cell accumulation 
and causes the contained serum to find its way out through 



July 11, 1885.] 



LEUF: THE EARLY ERADICATION OF SYPHILIS. 



39 



the surface breach, in which direction evidently is the least 
resistance. The induration of this, the chancre, is due to 
the close packing of the cells, the lessened blood-supply, 
and the spare amount of serous effusion. The long con- 
tinuance of the induration after it has healed over is also 
accounted for by the diminished local circulation and ab- 
normal condition of the vascular walls as being a decided 
interference in carrying on any absorptive process. 

The lymph-spaces and vessels in contact with these new 
products absorb the virus and convey it to the nearest 
lymph-glands. Here the virus is arrested and tends to set 
up a process identical with that existing at the place whence 
it just arrived. Eventually this is accomplished as well as 
it is possible in a different tissue. The result is an enlarged 
and indurated gland. We all know, too, how hard are 
these glands and how hard is the chancre. The typical 
primary sore does not really suppurate, for it simply throws 
off superficial layers of cells and debris with a limited 
amount of modified serum. A fact that is interesting to 
note now is that the glands involved, although enlarged and 
indurated, rarely suppurate. 

The production of leucocytes constitutes one of the 
functions of lymphatic glands, and from them the white 
corpuscles are at once admitted to the circulating blood. It 
is evident from this that, after a brief residence in these 
glands, the poison will be admitted to the blood and per- 
vade the whole body. The glands, however, as a rule, either 
destroy the virus they have brought to them, or render it 
innocuous, but not in all instances. It is hardly necessary 
to remark that in the case of syphilis we have a notable 
exception to this rule, but not without compensatory action 
of the gland — to wit, the retention of the virus for a suffi- 
cient length of time to admit of its mechanical removal. 
When the virus has penetrated those parts of the glands 
which are about to be launched into the circulating blood, 
the first step toward general infection has been taken. Ad- 
ditional loads of virus are thereafter constantly being thrust 
into the circulation and carried by it to all parts of the 
body. The other lymphatic glands being more susceptible 
to the influence of this and similar poisons than an)' of the 
other tissues, it is but natural that a general glandular dis- 
turbance should note the beginning of secondary symptoms, 
and that is actually what occurs in most instances. That 
the more superficial glands should be the ones mentioned as 
being enlarged at this time is only natural, for the deeper 
ones are not felt by the physician. Therefore does it happen 
that we are usually told that the cervical and supra-troch- 
lear glands are the ones most commonly found enlarged at, 
or just preceding, the onset of secondary symptoms. 

When we consider that of all disorders, excepting 
phthisis, there is probably none that is so malign in its 
effects upon our species as syphilis ; when also we regard 
the fact that a very large proportion of the victims of this 
affection are a prey to heredity ; and when, lastly, we reflect 
upon the present utter impossibility of preventing a general 
systemic syphilitic infection, and that" too in defiance of 
valuable palliative medicinal resources — I say, then, it must 
be admitted that any therapeutic measure that may be pro- 
posed for the eradication of syphilis previous to systemic 



infection is justifiable, if based on rational grounds. Not 
only is it justifiable, but it is unmistakably our duty to 
attempt these means if they give a reasonable promise of 
success. 

In the light of established facts, it is hard to believe 
that well-informed men still exist who will not admit the 
purely local nature of the chancre and resulting enlarge- 
ment of the nearest lymphatic glands. It is a widely known 
fact that a person having syphilis is unable to develop a 
second primary lesion so long as he gives evidence of exist- 
ing constitutional infection. Less widely known is the 
equally well-established fact that additional chancres may 
be developed ad libitum up to a short time before the out- 
break of symptoms denoting constitutional infection. 

In fact, the strongest claim for the curability of syphilis 
is based upon this very fact of a person with general symp- 
toms being uninoculable with the same disease. He enjoys 
absolute immunity from additional infection, and must be 
cured to be at all susceptible of reinfection and the develop- 
ment of a second chancre after having once suffered consti- 
tutional syphilis. 

If this is the correct view, and surely it is the most 
reasonable one, it is equally as certain that constitutional 
syphilis does not exist up to a short time before the second- 
ary eruptions, because a second chancre or series of chan- 
cres may be developed either by. auto-inoculation or hetero- 
inoculation during this particular period. 

In the treatment of any disease, it should be our first 
effort to attempt its abortion, and of none can it more truly 
be said that such attempt is our first and imperative duty 
than syphilis. Complete excision of all the structure har- 
boring the virus while it is still local would positively abort 
the disease. At present it appears that the chancre and 
nearest set of lymphatic glands are the only structures 
affected during this primary period. Their thorough ex- 
cision promises to effect the immediate termination of the 
disease, if accomplished sufficiently early. I should call 
sufficiently early any time previous to the appearance of 
secondary symptoms, and while the glands were still not 
much enlarged. All measures of this kind would be, how- 
ever, absolutely contra-indicated after the outbreak of the 
secondary stage. 

As regards the mode of operating, I think one thing 
very important and essential to success. It is that, inasmuch 
as glandular infection is due to material coming from the 
chancre, the safest way would be to remove the primary 
sore first and the glands afterward. Then, again, as the 
virus traverses gland after gland in regular order, reaching 
the one farthest removed after it has affected the nearer 
ones, it would be most safe to begin the glandular excision 
with the removal of the most distant one first and endinsr 
with the nearest and first affected. 

I recognize at once one possible source of failure in this 
treatment, and that is that some of the virus may be -re- 
tained in the lymphatic vessels between the excised sore 
and glands and permit of its absorption through collateral 
channels. This is guarded against, as far as possible, by 
the elimination of the active source of infection, the chan- 
cre, before the absorbents are cut off from their receiving 



40 



CURTISS: IMMUNITY IN DISEASE. 



[N. Y. Med. Joor., 



glands. Perhaps it would be well to allow several hours to 
elapse between the excision of the sore* and of the glands, 
so as to admit of the convergence of all the virus in the 
lymphatics to the glands about to be extirpated. Or, best 
of all, it would be most advisable to excise all the lym- 
phatics between the chancre and glands if at all affected, 
and possibly it would be still better to always excise these 
vessels, whether they appear to be affected or not. 

Only clinical experience and experimental research can, 
however, positively settle this point, and it is for the pur- 
pose of gaining this valuable experience as soon as possible 
that I have thus early offered this paper. If every man 
will cast aside his prejudices and attempt this abortive 
treatment of syphilis, we shall soon see demonstrated the 
fallacy or correctness- of this view. That it will prove cor- 
rect I have not the least doubt. It is only necessary to 
cast our eyes about and note the increased percentage of 
cures from carcinomatous excisions, since complete extirpa- 
tion of the whole set of lymphatic glands nearest the neo- 
plasm has come into vogue, to gain hope and confidence 
for the method of cure herein advocated. These glands, be 
it remembered, in operations for carcinoma, are thoroughly 
excised, although very often without the slightest evidence 
of disease. We have but to recollect the character of 
syphilis and its associations to feel the deepest commisera- 
tion for the innocent progeny who inherit the disorder. 
For this reason alone, if for no other, every rational means 
ought to be tried, and is justifiable, to prevent its spread 
not only around us but to future generations. 

Perhaps many former advocates of chancre excision will 
be opposed to this abortive plan of treatment because of 
the almost generally conceded failure of that half-way the- 
. rapeutic measure. Yet even this method may be all that is 
necessary in rare instances where the glands have not yet 
received any of the virus. I am willing to believe that 
some of the reported cases of cure in this way were actual 
instances of aborted syphilis. It is to be hoped, therefore, 
that those gentlemen who once championed chancre ex- 
cision, and, of course, those who do so still, will be the first 
to take in hand the practical testing of the more thorough 
method it seems to me so proper to advocate. 

Deeming the foregoing sufficient an outline to subserve 
the purpose of creating intelligent discussion on this question, 
I will complete my remarks with a few additional statements. 

My object has been to be fair and temperate in all that 
has been said. Although readily admitting plenty of room 
for honest differences of opinion in more than one part of 
my argument, I have refrained from attempting a systematic 
refutation of everything that seemed inconsistent from my 
standpoint, as it would only have interfered with the real 
objects of this paper. It is also well to recollect that the 
deductions I have made are based on the rule of behavior 
in syphilitic processes and their manifestations. Excep- 
tions to these general rules in the clinical history of this 
disorder are many and various, yet, if thoroughly analyzed, 
will be found to have no confuting effect upon the preced- 
ing argument. Even this, though, is only a rule, and also 
may have its exceptions, and exceptions, be it remembered, 
are often proof that rules exist. 



I have been as general as possible in the treatment of 
this question instead of being more specific, so that it 
should have the widest application and be followed by the 
broadest and most profitable discussion. The failure to 
mention the names of authors, or relate interesting and im- 
portant experiments and cases, must not be construed in 
any other sense than that the object was to avoid undue 
complexity and to save time. The great and only point at 
issue in the discussion of this question is, How soon after 
inoculation does systemic infection occur? 

In the hope that the discussion of this question will be 
frnnk and constantly to the point at issue, I have the honor 
of submitting to your judgment this argument on the earl)' 
and prompt eradication of syphilis for all that it is worth. 

IMMUNITY IN DISEASE. 
By ROMAINE J. CURTISS, M. D., Joliet, III., 

PROFESSOR OP HYGIENE IN THE COLLEGE OF PHYSICIANS AND SURGEONS, 
CHICAGO. 

The paper read by Dr. R. G. Eccles before the Brook- 
lyn Pathological Society, and published in the " New York 
Medical Journal," May 23d, refers to a subject which must 
eventually be settled. People will never be contented with 
the phenomena of disease, in relation to the causes, without 
a generalization which will cover the whole group of phe- 
nomena. The hypothesis of gravitation and that of the ex- 
istence of a light-ether explain the phenomena of the uni- 
verse relating to the motions of the spheres, and also the 
phenomena of light. What gives immunity in disease, what 
causes disease, and how do the causes act ? are leading ques- 
tions that must all be grouped together under one generali- 
zation which can explain them all, and I take it that any 
contribution looking to this end will be welcome to the 
profession. 

Before proceeding to actual work, it may be useful to 
examine the methods of doing this particular kind of work 
— to get the tools in good working order. I believe it is 
understood that whatever classes, orders, or varieties of 
things or phenomena we are studying — whether they be 
affairs of common life, or any special science, or whether 
the most complex questions that confront the philosophers- 
one of the objects of our study is to generalize laws from the 
things or phenomena, and the method or tool with which we 
work is hypothesis. It is a " cut-and-try " method. The 
hypothesis is designed to occupy the place of a general 
cause or antecedent to the whole group of questions under 
consideration. In selecting an hypothesis, care is required 
to be certain that the selection is a real cause in Nature, or 
else can be proved to be, and, when the selection is made, 
it appears that we have the question to settle next that the 
hypothesis is capable of causing such results as we are 
studying, and at the same time it must be proved that other 
supposed causes, or hypotheses, are not sufficient. 

I think this is a fair conception of the method employed 
in the study of all things and phenomena, including dis- 
ease ; and now, before proceeding further, it is necessary to 
define what is meant by immunity from disease. 

This inquiry being limited to the zymotic diseases, the 
meaning of immunity from disease must be that the organ- 



July 11, 1885.] 



GURTISS: IMMUNITY IN DISEASE. 



41 



ism can by soma means resist the living agent of disease. 
The power of resistance, whatever it may be, is acquired, 
as we certakily know, by an attack of the disease; and it is 
known that this power is also acquired by heredity. A 
person may be exempt from the attacks of given species of 
parasites, by reason of a former battle with the same species, 
or a variety of the same species, or the person may have 
immunity from the successful attacks of these enemies which 
he obtained by heredity from a long line of parasite-pestered 
ancestry. 

Unless it can be proved that people inherit the actual 
germs of disease, the law of heredity must impose the in- 
ference that, instead of inheriting a disease, persons inherit 
an immunity from disease, or else fail to inherit the immu- 
nity. The heredity of disease would appear to be negative — 
that is, a person inherits the disease simply because he fails 
to inherit an immunity. This view of the question of he- 
redity will fully explain the fact that consumptives and 
syphilitics and'thc victims of other hereditary diseases are 
the victims of these diseases because their ancestors have 
not acquired, by natural selection or by actual combat with 
the infectious causes, an immunity from the diseases. 

We know very well that immunity from such a disease 
as small-pox in an individual is acquired by an actual com- 
bat with the infectious cause of small-pox. The inference 
must follow, therefore, that the people who escape the zy- 
motic diseases, by reason of personal immunity or by reason 
of a successful vital or physical resistance to the germs, do 
so not because they have failed to encounter the germs or 
failed to inherit them, but because they have inherited the 
physical resistance from ancestors who acquired the same 
by reason of having the disease. 

But we find that immunity from disease has quite indefi- 
nite relations to time. In a certain ratio the immunity lasts 
a life-time, but in a far larger ratio it lasts for only a year 
or a few years. Probably, if an average could be known, it 
would be found that seven or eight years would express it. 
Now, whatever the immunity may be, it is evident that it is 
not lasting enough or forcible enough, in more than a small 
ratio of cases, to make much impression on hereditary trans- 
mission. Suppose one hundred people have small-pox ; pos- 
sibly out of this number there might be twenty instances 
where the immunity would be powerful enough to cause 
more or less impression on the forces of heredity. 

The two great forces of the development of all organ- 
isms are atavism and variability. Development is a result- 
ant of these two forces. Behind them both are the most 
complex antecedents pertaining to the struggle for exist- 
ence ; but these complex antecedents, grouped as they all 
are under two heads, all converge into the two forces which 
we understand as atavism and variability. The character 
of human development, from the mental and moral peculi- 
arities to even the color of the skin and the stature of the 
man, must be referred to the interactions of these two forces 
for a solution, and we must look to these things also for a 
solution of the problem of immunity from disease. 

From these data there is no better inference than the 
hypothesis that an actual attack of pathogenic organisms 
produces a variation of structure, the character of the varia- 



tion and the structure subject to the variation being deter- 
mined by the nature or method of onslaught and the tis- 
sues or cells that are attacked. Following up these special 
lines, we find that different pathogenic organisms attack 
different portions of the body, and that the method of war- 
fare is by poisons. 

To fortify this hypothesis it may be mentioned that liv- 
ing things which are adapted to each other as a food-supply 
must kill each other or catch each other first, and I think 
the two methods of causing death are by mechanical means 
and by poisons. Animals use stratagem, speed, tooth, beak, 
claw, muscles, and poisons, while the pathogenic bacteria use 
poisons. The micro-organisms, it is supposed, absorb their 
diet by osmosis, and it can not be imagined that this force 
of absorption can overcome the vital or physical integrity 
of a tissue-cell, and therefore the inference is that, if the cell 
resists the absorptive force of the micro-organism by its 
quality of life, it must resist the poison of the same agent 
by a variation of its vital or physical power of resistance, 
which is acquired by actual combat. 

If the ancestor of the antelope was given an occasional 
chase by a personal enemy — for instance, a wolf — and suc- 
ceeded in escaping, no one will dispute the fact that the an- 
telope obtained its speed by such means, and transmitted 
this quality to its progeny. The difference in speed be- 
tween the ancestor of the antelope and the modern species is 
the measure of the variation produced by actual combat with 
a personal enemy. The struggle for existence of this special 
character caused this variation. If a whole herd of wolves 
should now be turned into an inclosed lot with an antelope, 
it is quite likely that the antelope would fall a victim, but 
this would not disprove the fact that in a state of nature the 
speed of the antelope was developed in this manner, and 
that nature, or natural selection, by this means has preserved 
the antelope as a species. This bit of biology explains a 
special instance of the law of variability. But now, sup- 
pose the species of wolf is destroyed ; the force behind this 
variation is removed; the antelope has no care to exercise its 
speed, and gradually loses its power, and, in time, by what 
is called atavism, it again resembles, in this respect, its an- 
cestor. 

The pathogenic bacteria are organisms of prey, and a 
disease is simply a combat between the cells and the organ- 
isms which are there after food. It is difficult or impossible 
to say how a poison may destroy a cell, but it is certain 
that the effect of the poison is to destroy life, and such is 
its object. If it is true that disease is thus caused by de- 
stroying the life of cells, then it is true that immunity may 
be acquired by a variation of the cell in structure or func- 
tion, so that it may resist the poison. The question of 
drug-tolerance by cells is established by experiments with 
morphine, alcohol, etc. There is no scientific method of ex- 
plaining this fact except by the inference that a variation in 
structure and function is produced in the cell as a conse- 
quence of actual combat with the poison. The cell may 
secrete an antidote to the poison of the enemy, or its mo- 
lecular elements may be rearranged in such a manner that 
the poison is not effective. Either of these propositions 
may do as an hypothesis, and, though they may be difficult 



42 



BOOK NOTICES. 



[N. Y. Med. Jock., 



to verify, they are true verce causae in nature, and they can 
explain the phenomena of the immunity from disease, singly 
and collectively. 

Suppose, now, the cause of disease is removed ; the cells 
which have acquired a variation of structure or function, by 
the law of atavism, lose this variation. In time the im- 
munity ought to run out, and we find this to be true. The 
immunity from, or protection given by, one attack of disease 
varies, in time, in direct proportion to the severity of the 
disease, as a ride. There is no other method of explaining 
this phenomenon except by these laws of variability, ata- 
vism, and natural selection. 

The artificial tests for the protection thus afforded 
against disease, which consist in injecting a large quantity 
of pathogenic bacteria into an animal which is sufficiently 
protected to resist the attacks of disease by natural inva- 
sion, resembles the method mentioned of testing the pro- 
tection given the antelope through its speed by exposing it to 
a pack of wolves in an inclosure. The conditions of nature 
in these instances are not imitated, and, consequently, no in- 
formation of value can be inferred from such experiments. 
{To be concluded.) 



A Practical Treatise on Nasal Catarrh and Allied Diseases. By 
Beverley Robinson, A. M., M. D. (Paris), Clinical Professor 
of Medicine at the Bellevue Hospital Medical College, etc. 
Second Edition, Revised and Enlarged, with One Hundred 
and Fifty-two Wood Engravings. New York: William 
Wood & Co., 1885. Pp. xii-276. 

Those who were so fortunate as to read the first edition of 
this excellent work will hardly recognize it in the elegant sec- 
ond edition now before us. To the book as it first appeared 
five chapters have been added. These are devoted to the 
study of: 1. Aural Complications of Catarrhal Affections of the 
Nose. 2. Deflections of the Nasal Septum and Bony Obstruc- 
tions of the Nasal Passages. 3. Ulcerous Coryza. 4. Adenoid 
Vegetations at the Vault of the Pharynx. 5. Mucous Nasal 
Polypi. 

The text of the original edition has also been carefully re- 
vised, and changes or additions made where required, while 
ninety-six illustrations have been added, and the work made 
complete up to the date of its issue. Want of space forbids the 
extensive review which should be given it. There is much in it 
which deserves commendation, and every evidence of experi- 
ence in the use of the methods advised and of painstaking care 
in their presentation. 

The main fault of the author is an undue redundancy of 
style, which adds unnecessarily to the length of his chapters 
without in any wise contributing to their clearness. 

Among the cuts the reader will recognize the familiar face 
of many an old friend. Figs. 26 and 27 might well have been 
omitted. 

Compared with the substantial merit of the work, however, 
these are trifling matters. It will be difficult to find in any 
language a more exhaustive and thorough treatise upon nasal 
catarrh, so that the book should, and we believe will, have a 
wide circulation 



Post- Nasal Catarrh and Diseases of the Nose causing Deafness. 
By Edwakd Woakes, M. D., Senior Aural Surgeon and Lec- 
turer on Diseases of the Ear, London Hospital, etc. Illus- 
trated with Wood Engravings. Philadelphia: P. Blakiston, 
Son h Co., 1884. Pp. 224. [Price, $1.50.] 
This is an American reprint from the third English edition. 
The first chapter is devoted to some observations on the cor- 
relating and reflex functions of the sympathetic nervous sys- 
tem. Then follow two chapters on the vEtiology of Acute and 
Chronic Catarrh, in which are considered what Woakes calls the 
" pre-catarrhal state," and the mechanism of "taking cold." 
The chapter on the Hygienic Management of the " Catarrhally 
Predisposed" is full of useful hints and suggestions. The diffi- 
culties and importance of posterior rhinoscopy are well em- 
phasized, and a most excellent account is given of the method 
of anterior rhinoscopy. There have been so many additions 
made to the original work that the English publishers thought 
it wise to issue the new matter in a volume by itself, and this 
is what is presented to the medical profession. It is a most 
clear and valuable contribution to our hitherto rather defective 
knowledge of diseases of the naso-pharynx. Some of the au- 
thor's views will certainly not be accepted without careful con- 
sideration and repeated observations; but those on therapeutics 
will meet with cordial commendation. 



A IIand-boo~k of the Diseases of the Eye and their Treatment. 
By Henky R. Swanzy, A. M., M. B., F. R. C. S. I., Surgeon 
to the National Eye and Ear Infirmary, etc. With Illustra- 
tions. New York: D. Appleton & Co., 1884. Pp. xv-437. 
Mr. Swanzy has here given to the medical student and gen- 
eral practitioner a most admirable hand-book upon what is per- 
haps the most important and extensive of the special depart- 
ments of medicine. The author, who, as a former assistant to 
von Graefe, has been brought up in an admirable school and 
whose experience has been very large, treats his subject in a 
very thorough manner, while the style is readable and clear. 
There is a minuteness of detail in regard to treatment which 
will prove especially attractive to the student. The book con- 
sists of twenty-two chapters, the first three of which are de- 
voted to elementary optics, anomalies of refraction and accom- 
modation, and the theory and use of the ophthalmoscope. Under 
the latter head there is a full and excellent account of the 
method of determining the refraction by the ophthalmoscope 
known as " retinoscopy," now much employed in England. A 
special chapter is devoted to a consideration of the motions of 
the pupil in health and disease, which is a concise and admira- 
ble discussion of a subject of great importance to the general 
practitioner as well as to the ophthalmologist. Under this head 
we find both irritation- and paralytic-myosis, and irritation- and 
paralytic-mydriasis. This is prefaced by a consideration of the 
size of the pupil in health, and of the action of mydriatics and 
myotics on the pupil. A new feature in ophthalmic literature 
is to be found in the insertion upon the inner side of the cover 
of a set of Holmgren's wool-tests for the detection of color- 
blindness. The book is extremely well printed with clean, 
sharp type on tinted paper, and the illustrations are excellent. 
As a specimen of the book-maker's art, it is admirable. 



A Hand-book of Ophthalmic Science and Practice. By Henry 
E. J tiler, F. R. C. S., Junior Ophthalmic Surgeon to St. 
Mary's Hospital, etc. With One Hundred and Twenty-five 
Illustrations. Philadelphia : Henry C. Lea's Son and Co., 
1884. Pp. 467. 

Of the making of books on ophthalmic science there seems 
to be no end ; but very little fault will be found by any one 



July 11, 1885.] 



BOOK NOTICES. 



43 



with Mr. Juler's contribution to the library of opbthalmological 
text-books. It is a handsomely printed volume of about four 
hundred and fifty pages, well illustrated by plain and colored 
drawings and numerous colored lithographs of the fundus of 
the eye in health and disease. Some of the plates represent- 
ing pathological processes in the cornea, iris, and ciliary body 
are particularly good. The book consists of sixteen chapters, 
to the arrangement of which in their order of sequence some 
exception may be taken. There seems no very good reason 
why the crystalline lens, the vitreous humor, and glaucoma 
should be considered after the subject of color-vision and its 
defects, nor why the chapter on Diseases of the Orbit should be 
placed last. It is much to be regretted that in the chapter on 
Conjunctival Diseases the author does not clearly distinguish 
between membranous and diphtheritic conjunctivitis, instead of 
classing them under the same head. They are two distinct dis- 
eases, and should not by any means be confounded. It may be 
said that ophthalmic surgeons, at least on this side of the At- 
lantic, are almost unanimous upon this subject. Due promi- 
nence is given to Mr. Wolfe's operation by transportation of a 
flap without pedicle for correcting certain cases of ectropium, 
or lid defect. The chapters on the Visual Field, Color-vision, 
and Color-blindness, Anomalies of Refraction and Accommoda- 
tion, and the Ophthalmoscope are good, but it is necessary to 
state that they are all written from the English standpoint, 
which differs in some respects decidedly from that prevailing in 
this country. The pathological work is mainly represented by 
the colored drawings, there being very little in the text. The 
importance of the ophthalmoscope as a means of measuring 
the refraction is well stated, and there is a very good descrip- 
tion of the method known as retinoscopy, or the shadow test, 
which, however, can be employed only by the practiced expert. 
In the chapter on Diseases of the Muscles the author prefers 
Anderson Critchett's operation for advancement of a muscle. 

Notes on Operations on the Eye. By Ram Kishen, L. M. S., 
Lahore, Assistant Surgeon. Lahore: Printed at the "Tri- 
bune" Press, 1884. Pp. 2-ii-78-iii. 

This little duodecimo volume of about eighty pages is by a 
native of the Punjab, and, as the author says in the preface, is 
an attempt to draw attention to the practical points in connec- 
tion with the principal operations in ophthalmic surgery. There 
are no illustrations, and the English is awkward and at times 
verging on the ludicrous. The operations are, however, suffi- 
ciently well described. 

A Guide to the Diseases of Children. By James Frederick 
Goodhart, M. D., F. R. C. P., Assistant Physician to Guy's 
Hospital, and Lecturer on Pathology in its Medical School, 
etc. Revised and edited by Louis Starr, M. D., Clinical 
Professor of Diseases of Children in the Hospital of the Uni- 
versity of Pennsylvania, etc. Philadelphia : P. Blakiston, 
Son & Co., 1885. Pp. 738. [Price, cloth, $3; sheep, $4.] 
The special design of this book, the author tells us in his 
preface, is to furnish to medical students a manual for ready use 
in this department. A careful examination of the book will 
convince any one of the fact that he has succeeded admirably. 
We predict that its use will not be limited to students, but that 
the practitioner will find it convenient, trustworthy, and ex- 
tremely suggestive upon most of the practical questions which 
it discusses. It is pre-eminently a book written out of the au- 
thor's personal experience. Every page bears witness to the 
fact that he has been a wide and careful observer. The book is 
written in a readable, forcible style, and the points are clearly 
stated. The author possesses the rare faculty of condensing 
minor details and bringing out salient points vividly. Being at 



the same time a teacher in pathology, he has not neglected that 
branch of his subject, although the size of the work has made 
it necessary to condense very much. 

When there is so much to praise, it is not easy to say which 
parts of the book are the most valuable. The articles on whoop- 
ing-cough, empyema, scarlatina, and diphtheria are especially 
good. The author holds that the last-mentioned is distinct from 
membranous croup, but states that this distinction must rest on 
clinical and not on histological grounds. His treatment of em- 
pyema is by early evacuation, preferably by incision, although 
he says other means may be tried in some cases. He reports 
twenty-six cases treated consecutively, with but a single death. 
We can not quite agree with him that there is no advantage in 
distinguishing between the two forms of acute pneumonia. 

There are many minor matters in which the book might be 
improved, but its excellences are so many that they can be 
overlooked. On the whole, we consider the work one of the 
best of its kind that have appeared in a long time. It will un- 
doubtedly demonstrate its right to existence. 

The work of the American editor has been fairly done, but 
we should have been quite as well pleased with the book in its 
original form. He has avoided the error of too extensive addi- 
tions. In the translation of the expressions of the British Phar- 
macopoeia into those of the United States Pharmacopoeia he has 
rendered a real service. 

The Theory and Practice of Medicine. By Frederick T. Rob- 
erts, M. D., etc., Professor of Materia Medica and Therapeu- 
tics, and of Clinical Medicine, at University College, etc. 
With illustrations. Fifth American Edition. Philadelphia : 
P. Blakiston, Son & Co., 1884. Pp. 1008. 
Dr. Roberts's book is sufficiently well known to need but 
little reference to it. This is the fifth edition — an evidence in 
itself of its favorable reception by the profession. It is the 
text-book used in many of the medical schools in this country. 

S : nce the last edition the author has revised his work 
throughout, and has incorporated the results of discussions 
which have taken place since the appearance of the last edition 
in so far as they seemed of practical importance. He has paid 
special attention to diseases of the nervous system in this edi- 
tion. 

He discusses Koch's theories on the Bacillus tuberculosis, 
and gives a plate of illustrations of the bacillus. He does not 
commit himself to a positive opinion, but closes his discussion 
of this subject with the following significant remark : " It would 
be premature at present to come to any positive general con- 
clusion on the subject ; but there seems to be no doubt as to 
the possibility of tuberculosis being developed by infection from 
within and from without under certain circumstances." The 
discussion on the cholera bacillus had not taken place at the 
time this edition was issued. The author has here, as in pre- 
vious editions, included skin diseases, which seems odd, at least 
to physicians in this country. 

The work is an admirable one, and fully deserves the excel- 
lent reputation it has gained both as a text-book and as a safe 
and reliable book for the practitioner. 

BOOKS AND PAMPHLETS RECEIVED. 

Bacterial Pathology. A Series of Papers on the Exhibits 
at the Biological Laboratory of the Health Exhibition. Under 
the Charge of Watson Cheyne. Reprinted from the " Lancet." 
New York : The Industrial Publication Co., 1885. [Price, 25 c.] 

Report of the New York Hospital Saturday and Sunday 
Collection of 1884. 

Introductory. Fifth Annual Report of the [? New York] 
State Board of Health. 



LEADING ARTICLES. 



[N. Y. Med. Joub., 



the 



NEW YORK MEDICAL JOURNAL, 

A Weekly Review of Medicine. 



Published by 
D. Appleton & Co. 



Edited by 
Prank P. Poster, M. D. 



NEW YORK, SATURDAY, JULY 11, 1885. 



THE RUMP CONGRESS OF 1887. 

It was scarcely to be expected that those eminent physi- 
cians of Philadelphia whose action in regard to the organization 
of the Ninth International Medical Congress we recorded last 
week would find themselves alone in the resolve to stand aloof 
from a gathering which, as is constantly growing more and 
more manifest, will be an international congress only in name. 
As will be seen by our news columns, Boston and Baltimore 
have promptly followed suit, and, like the Philadelphia resolu- 
tions, those passed in Boston and Baltimore are signed by men 
whose names are indissolubly connected with American medi- 
cine. Whether organized action of like significance will be 
taken in New York and elsewhere, it is impossible to say, but 
this much is certain, that some of the New York men whom 
the new committee of the American Medical Association placed 
among the officers of sections have no sympathy with the os- 
tensible motives— far less with the real motives— which led a 
little band of malcontents to plot the destruction of the Wash- 
ington meeting. Even if those gentlemen do not formally ex- 
press their feelings in the matter, there can be no doubt that 
they will abstain from any participation in the Washington 
meeting. 

It looks, indeed, very much as if the part of Hamlet would 
be left out at Washington in 1887, for our foreign colleagues 
will in all probability decide not to cross the Atlantic in any 
great numbers for the pleasure of meeting the rump of the 
American profession. And all this disgrace is the logical out- 
come of the false and artificial issues which for the past three 
years have enabled men in no way representative of the profes- 
sion to masquerade as its leaders, through the medium of that 
degenerate and utterly ridiculous concern the American Medi- 
cal Association. That organization long ago ceased to work for 
the benefit of the profession, and for a number of years past its 
annual meetings have been little more than scenes of the most 
shameless intrigue and demagogism. From the nature of its 
make-up, and from the character of the men who manipulate it 
year after year, the hope is exceedingly untenable that, within 
any reasonable period, this state of things will be mended. It 
has made itself as odious as any board of aldermen in the land, 
but, unfortunately, it is so intrenched in jugglery that to draw 
its fangs is almost as unpromising a task as that of uprooting 
municipal misgovernment. Difficult as this task is, however, its 
accomplishment is only a question of time, and it is even now 
evident that, for at least five years past, the association has 
owed its continued semblance of life to the force of the familiar 
politicians' plea that, whatever its shortcomings might be, it 



was, after all, the only organization of a national character that 
professed to be in any way representative of the whole profes- 
sion. If its hangers-on think that its steady degradation is for 
ever to be condoned on the strength of this plea, we would 
point them to what lately happened to one of the great politi- 
cal parties of the country. The plea amounts to this, that any- 
thing which the American Medical Association chooses to do ia 
better than no concerted action at all. How long this specious 
cry is likely to prove potent may be judged of from the fate 
which, in the history of the world, has uniformly overtaken 
organized villainy sooner or later, no matter what its seeming 
power, and no matter how white its hypocritical cloak. 

The crowning act of infamy in the downward career of the 
American Medical Association has been achieved in the wreck- 
ing of the American meeting of the International Medical Con- 
gress, a meeting which, but a year before, it had seemed to be 
doing its best to make creditable and successful. Doubtless it 
may be said with truth that the action it took at New Orleans 
is not in consonance with the deliberate convictioos of the 
great mass of its members, but that consideration is in fact a 
most telling arraignment of its methods of dealing, for an or- 
ganization which fails year after year to bring out the real 
sentiments of its members falls conspicuously short of the aims 
it ostensibly has at heart. 

That the wreck of the Congress of 1887 has not been irre- 
trievably wrought we can now see no reason to hope. It is, of 
course, not to be supposed that the Congress will formally 
reconsider its acceptance of the invitation extended to it by the 
American profession, but the conclusion can scarcely be avoided, 
nevertheless, that the European members who would add luster 
to the gathering will individually make up their minds not to 
attend the meeting, and it will simply go by default. 



NEWS ITEMS, ETC. 

Infectious Diseases in New York.— We are indebted to 
the Sanitary Bureau of the Health Department for the following 
statement of cases and deaths reported during the two weeks 
ending July 7, 1885 : 



DISEASES. 


Week ending J une 30. 


Week ending July 7 


Cases. 


Deaths. 


Cases. 


Deaths. 




13 


4 


13 


4 




29 


7 


35 


5 


Cerebro-spinal meningitis. . . . 


1 


1 


4 


4 




100 


25 


56 


12 




63 


35 


41 


21 




0 


0 


3. 


0 



Yellow Fever. — A single case was reported to the New 
Orleans Board of Health by a physician last Saturday, and two 
inspectors confirmed his diagnosis. The patient was convales- 
cent at the time, and we have no information of the spread of 

the disease. 

Small-pox. — An Astoria physician encountered a case of 
small-pox at Hunter's Point last week, and at once notified the 
sanitary officials of Long Island City, who, however, seem to 
have been in no haste to adopt measures for the protection of 
the community. Early this week a case was discovered in New 
York, in the upper part of Fourth Avenue. The patient, a 
child, was removed to the Riverside Hospital. 



July 11, 1885.] 



MINOR PARAGRAPHS. 



45 



The International Medical Congress and the Medical 
Profession of Boston.— At a meeting held in the Medical Li- 
brary Building, in Boston, on July 2, 1885, the following reso- 
lutions were unanimously adopted : 

Whereas, We had been led to believe that the authority to 
organize and control the Ninth International Medical Congress 
had been permanently delegated by the American Medical Asso- 
ciation to its original committee, thus providing against any 
radical changes in its published programme; and 

Whereas, The American Medical Association has revised the 
action and annulled appointments of that committee in a way 
which we regard as detrimental to the interests of the medical 
profession of America and fatal to the success of the Congress ; 
therefore be it 

Resolved, That we, the undersigned, members of the medical 
profession in Boston and vicinity, concerned in the organization 
of the Ninth International Medical Congress, decline to hold 
any office in said Congress as now organized. 



Robekt Amory, 
G. M. Garland, 
IT. P. Bowditch, 
R. T. Edes, 
J. J. Putnam, 
Franois Minot, 
J. R. Chadwick, 
C. F. Folsom, 
Hasket Derby, 
S. G. Webber, 
T. M. RoTcn, 

T. FlLLEBROWN, 



R. H. Fitz, 
Thomas Dwight, 
C. J. Blake, 
J. C. Warren, 
O. F. Wadsworth, 
S. J. Mixter, 

F. I. Knight, 

G. H. Lyman, 
Jacob L. Williams, 

H. W. Williams, 
H. P. Walcott, 
J. Orne Green, 



E. Wiggles worth. 

The International Medical Congress and the Medical 
Profession of Baltimore. — In consequence of the dissatisfac- 
tion caused by the recent action of the new Committee on the 
Organization of the Ninth International Medical Congress, the 
subjoined paper has been signed by those whose names are ap- 
pended. 

Whereas, The new Committee on the Organization of the 
Ninth International Medical Congress, at its recent meeting, 
held in Chicago, made such changes in the arrangements for the 
Congress as, in our opinion, will mar its success, and will prove 
injurious to the interests of the medical profession, it is there- 
fore 

Resolved, That we, the undersigned, disapprove of the action 
of the committee, and decline to accept the positions to which 
we have been appointed under it : 



I. E. Atkinson, 
S. C. Chew, 
Julian J. Chisolm, 
Christopher Johnston, 
William Lee, 
John N. Mackenzie, 



Richard McSherry, 
F. T. Miles, 
Alan P. Smith, 
Samuel Theobald, 
L. McLane Tiffany, 
H. P. C. Wilson. 



The New York Post-Graduate Medical School and Hos- 
pital. — Dr. Horace T. Hanks has been elected professor of dis- 
eases of women, and Dr. Lewis S. Pilcher professor of clinical 
surgery. 

The New York Polyclinic. —The "Journal of Comparative 
Medicine and Surgery " announces that the faculty of the Poly- 
clinic, of which Dr. Frank S. Billings is a member, has consented 
to his teaching special classes of veterinarians in the pathologi- 
cal laboratory of the institution. 

The Water Supply of Manhattan Beach having been made 
the subject of complaint, the local health officer, Dr. R. L. Van 



Kleek, has caused an examination of the water to be made, and 
reports that it is of good quality. 

The New Hospital for Infectious Diseases, on North 
Brother Island, is nearly ready for occupation, and it is expected 
that the Riverside Hospital will soon be abandoned. 

Cremation in Buffalo. — It is announced that a crematory 
is soon to be built near the cemetery in Buffalo, the incinerating 
apparatus for which is to be made in Milan, Italy. 

The Glasgow Obstetrical and Gynaecological Society.— 

Our English exchanges announce the organization of a society 
with this title in Glasgow, with Professor Leishman for presi- 
dent. 

The Royal Academy of Medicine, of Rome, according to 
the "Lancet," has admitted the British delegates to the recent 
International Sanitary Conference, Sir Guyer Hunter, Dr. Thorne 
Thome, Sir Joseph Fayrer, and Dr. T. Lewis, as honorary fel- 
lows. 

The Death of Dr. Joseph Estabrook, of Rockland, Me., 

took place last Sunday. The deceased was eighty-seven years 
of age, and is said to have been the oldest graduate of Williams 
College at the time of his death. He was an alumnus of the 
Harvard Medical School. Many years ago he was the demon- 
strator of anatomy in the Medical School of Maine, and had been 
president of the Maine Medical Association. 

The Death of Dr. G. B. Soresina, the distinguished Italian 
syphilidologist, is announced in the " Gazzetta degli Ospitali." 
The deceased was eighty-three years of age. 

Army Intelligence.— Official List of Changes in the Sta- 
tions and Duties of Officers serving in the Medical Department, 
United States Army, from June 28, 1885, to July 3, 1885: 
Ainsworth, F. C.j Captain and Assistant Surgeon. Relieved 
from duty at Headquarters Department of the Missouri. S. 
0. 93, Department of the Missouri, June 26, 1885. 
Taylor, B. D., Captain and Assistant Surgeon. Assigned to 
duty at Little Rock Barracks, Arkansas. S. 0. 139, Depart- 
ment of the East, July 1, 1885. 

Naval Intelligence.— Official List of Changes in the Medi- 
cal Corps of the United States Navy during the two weeks end- 
ing July If, 1885. 

Bransford, John F. Commissioned as surgeon on active list. 
June 16, 1885. 

Ross, J. W., Surgeon. Detached from Naval Laboratory, and 

waiting orders. June 30, 1885. 
Shafer, Joseph, Assistant Surgeon. For duty on board the 

U. S. Receiving Ship St. Louis, League Island, Pa. July 10, 

1885. 

Society Meetings for the Coming Week : 

Monday, July 13th: Boston Society for Medical Improvement; 
Gynjecological Society of Boston ; Burlington, Vt., Medical 
and Surgical Club; Norwalk, Conn., Medical Society (pri- 
vate). 

Tuesday, July Uth : Medical Societies of the Counties of Clin- 
ton (Plattsburg), Jefferson (Watertown), Madison, Oneida 
(Utica), Ontario (Canandaigua), Rensselaer, Schuyler, Tioga 
(Owego), and Wayne, N. Y. ; Norfolk District, Mass., Medi- 
cal Society (Hyde Park). 

Wednesday, July 15th : New Jersey Academy of Medicine 
(Newark). 

Thursday, July 16th : New Bedford, Mass., Society for Medi- 
cal Improvement (private). 



46 



LETTERS TO THE EDITOR.— PROCEEDINGS OF SOCIETIES. 



[N. Y. Med. Joitb., 



fetters to t|je debitor. 

THE MEDICAL PROFESSION IN CINCINNATI. 

Cincinnati, July 3, 1885. 
To the Editor of the New York Medical Journal: 

Sir: In your issue of May 30, 1885, page 608, appears a 
" Letter from Cincinnati," upon which I ask permission to make 
comment. Some of its statements are unjust to the medical 
societies and profession of Cincinnati. For the sake of brevity, 
I condense some paragraphs from the letter and place them 
in relation without special regard to their order in the letter. 

" About ten years ago Dr. Reamy, then a new comer, made 
the declaration in debate in the Academy to the effect that there 
were members of the Academy, in otherwise good standing, who 
were guilty of criminal abortion. . . . 

" Dr. R. was a member of the faculty of the Medical College 
of Ohio ; his immediate antagonists were of the faculty of the 
Miami Medical College. The third party, the Cincinnati Col- 
lege of Medicine and Surgery, kept its hands off and watched the 
fun." . . . The vote came. Dr. R. was vindicated. " The Mi- 
ami people said, No man can maintain his self-respect and re- 
main a member of the Academy. They resigned and organized 
the Cincinnati Medical Society." . . . The feelings then engen- 
dered have succeeded in keeping many people from both the 
Academy and the Cincinnati Medical Society, for in that way 
alone was it possible to maintain friendship with both factions. 
The result has been a dearth of good matter presented at both 
societies, . . . •' the generally meager attendance at the meet- 
ings particularly of the Academy and the Cincinnati Medical 
Society." . . . "The fact is that either animosity or apathy in- 
terferes with the popularity of both these societies." . . . 

Comment. — 1. Dr. Rearay's charge was in these words: 
" For we must not shut our eyes to the fact, known to us all, 
that there are members of the medical profession, in otherwise 
good standing, who sometimes commit abortions." The Acade- 
my of Medicine was not mentioned by the speaker. 

2. Neither the gentlemen who introduced the resolution ar- 
raigning Dr. R. for his utterances, nor either of the three gen- 
tlemen composing the committee on ethics conducting the prose- 
cution, were members of, or in any way connected with, the 
faculty of the Miami Medical College, nor have they since been 
so connected. 

3. One of the most active members of that committee was 
for some time an able lecturer in the Cincinnati College of 
Medicine and Surgery. And the present professor of surgery 
in this same college was one of Dr. R.'s most earnest support- 
ers during the controversy referred to. And one of the spiciest 
letters of the many received by Dr. R. during that controversy 
was written by the father of your Cincinnati correspondent, 
who was at that time one of the oldest and most active mem- 
bers of the Cincinnati College of Medicine and Surgery. 

4. Though a new society was organized, and though many 
of those who participated in its organization had recently re- 
signed from the Academy, there were many, and are now many, 
who are members of both societies. 

5. The membership of the Academy is as large as before the 
organization of the new society. The average attendance at 
stated meetings is as great, the papers read, cases reported, and 
discussions thereof are as able, interesting, and instructive as at 
any period in its history. An examination of its recorded pro- 
ceedings will prove the truth of this assertion. Many of the 
papers and discussions will compare favorably with the work of 
any similar society in the country. 

6. Though the attendance at the meetings of the Cincinnati 



Medical Society is not quite so large as that of the Academy, as 
the membership is not so large, yet the attendance is good, and 
their papers and discussions merit the same commendation as 
above given to the Academy. Both of the societies are popular. 
Of neither can it be said that "there has been a dearth of good 
matter presented." 

7. There is no bitter feeling held against the other by either 
of these societies. Nor is there any hatred between individual 
members thereof. Nor between the faculties of the Medical 
College of Ohio and the Miami Medical College. 

8. The statement that "the active participants in the old 
fight are gradually retiring from the field of active practice, and 
are, fortunately, quite unable to leave their hatreds as a heritage 
to the new generation," demands the following reply: Two or 
three of the participants in the old fight have died. Of those 
remaining, every one is in active practice, some of them doing 
six times more professional work now than then. As to 
hatreds, they have none. Personal and professional friendships 
prevail between the leaders on both sides. It is true the fight 
was "acrimonious," but, as no personal issues were involved — 
only misunderstandings as to the application intended by Dr. 
R. in bis original statement made in the Academy — it was quite 
natural that, after all was over, friendship should be restored ; 
and it was. All this occurred without an apology or explana- 
tion being made by the former antagonists in any instance. The 
absolute obliteration of ill-feeling which has for years existed 
may be considered exceptional, and is certainly commendable 
to all parties. 

It is the testimony of those who know best, that friendship, 
harmony, and good feeling never prevailed more supremely in 
the medical profession of Cincinnati than at present. 

The impressions sought to be made by the letter of your 
correspondent are therefore unwarrantable, and demand con- 
tradiction. 

But what prompted him ? His intelligence is well known ; 
that he wrote in malice toward any is not at all probable. That 
he would write what he knew to be untrue I do not believe. 
What then? 

Residing and practicing in another town, he can not attend 
the meetings of the societies in Cincinnati nor mingle with the 
profession, and has therefore been misled as to his facts. 

Very respectfully, 

Tbad. A. Reamy. 



fJroteebings of Soriet'us. 

NEW YORK PATHOLOGICAL SOCIETY. 
Meeting of May 27, 1885. 
The President, Dr. John A. Wyeth, in the Chair. 

Epithelioma of the Tongue. — Dr. 0. W. Knight presented 
a portion of the posterior part of the tongue, the seat of epi- 
thelioma, removed after ligation of the lingual artery. 

Lipoma of the Back. — Dr. L. Waldsteix presented the speci- 
men, removed by Dr. Lange from a woman eighty-six years of 
age. The tumor was removed because of the presence of an 
ulcer of the skin which refused to heal. The specimen illus- 
trated the fact that lipomas sometimes developed and did not 
become reduced in size in persons in whom there was marked 
emaciation. 

Adeno-sarcoma of the Stomach. — Dr. Waldstein pre- 
sented a second specimen of adeno-sarcoma of the stomach, of 



July 11, 1885.] 



PROCEEDINGS OF SOCIETIES. 



47 



the diffuse variety, located chiefly at the fundus and cardiac 
extremity. The patient, forty-six years of age, had suffered 
extremely during the last four months of life. There were large 
quantities of granular detritus from division of the nuclei which 
had sometimes heen mistaken for micro-organisms. There had 
been marked jaundice, and a diagnosis of carcinoma of the liver 
was made, a tumor of the size of a pigeon's egg being mistaken 
for that disease. The autopsy showed the tumor to be the en- 
larged gall-bladder, the duct of which was partially obstructed 
by metastatic tumors of the lymphatic glands of the porta 
hepatis. 

Diphtheritic Laryngitis. — Dr. Joseph E. Winters pre- 
sented the lungs of a child nearly two years of age, which had 
died of exhaustion and asphyxia due to diphtheritic laryngitis. 
The disease had for some days been limited to the fauces, not 
involving the larynx for more than a week. When dyspnoea 
was present tracheotomy was proposed, but rejected by the 
father. The autopsy showed the presence of the exudate only 
for three fourths of an inch below the vocal bands. There were 
muco-pus and vascularization below that point. There was 
marked vascularization at the bases of the lungs, and in the 
anterior portion there was some degree of anaamia with unusual 
distension. 

Dr. C. C. Lee asked Dr. Winters what had been his experi- 
ence with Dr. O'Dwyer's laryngeal tube. 

Dr. Winters said that, the tubes having been so generally 
discarded in France, he had not employed them. 

Dr. Lee remarked that the tubes used in this city had ar- 
rested the progress of spasmodic disease and had saved lives 
where laryngotomy doubtless would have failed. He thought 
the tube might prove useful in cases of diphtheritic laryngitis 
by relieving dyspnoea when the parents would not consent to 
tracheotomy. 

Dr. Northrup remarked that at the New York Foundling- 
Asylum the tube had relieved urgent laryngeal symptoms almost 
immediately. He asked Dr. Winters whether in his experience 
the past season the false membrane had shown a strong tendency 
to extend downward into the bronohi. 

Dr. Winters said that most of the cases which he had seen 
were consultation cases, and he thought that when treated early 
the membrane had not extended much below the larynx. He 
thought the tendency of the exudate to spread would be greater 
in institutions than in private practice. 

Dr. H. J. Boldt said that, according to his experience dur- 
ing the past winter, the false membrane had shown a great 
tendency to extend below the larynx. 

Dr. J. C. Peters had employed frequent irrigation of the 
throat and used bichloride of mercury in cases of false mem- 
brane upon the top of the larynx, and the patients recovered 
without extension of the membrane downward. 

Pott's Disease ; Necrosis of all the Principal Long Bones. 
— Dr. W. P. Watson, of Jersey City, presented the specimens, 
consisting of certain vertebra}, removed from the body of a 
child five years of age, which had died of pneumonia. The 
child had first developed a swelling over the right thigh, which 
was said to have entirely disappeared. Afterward there was 
curvature of the spine in the cervico-dorsal region, reaching a 
right angle, but at no time was there paralysis. Abscesses also 
developed over the thigh and both wrists, and exsection of a 
considerable portion of the right radius and of the right knee 
joint and lower portion of the femur was performed. At the 
autopsy there was found to bo marked absorption of the fifth, 
sixth, and seventh cervical, and of the first and second dorsal, 
vertebras. It was remarkable that but very little compression 
of the cord had taken place. 

Frequent Recurrence of Pregnancy.— Dr. Watson also 



presented a foetus of the sixth week which was aborted a few 
days after the repair of a bilateral laceration of the cervix 
uteri. The patient was an English woman of robust health, 
who had been pregnant seven times in six years, three being 
single and four twin pregnancies. Only two of the pregnancies 
went to full term. Menstruation had occurred less than a 
month before the cervix was repaired, and there was no reason 
to suspect pregnancy. 

Multilocular Cystoma of the Right Ovary with Hydro- 
salpinx, and Cystic Degeneration of the Left Ovary with 
Simple Salpingitis.— Dr. R. W. Wilcox presented the speci- 
mens removed from a patient thirty-seven years of age, married, 
never pregnant. The enlargement of the abdomen had been 
observed for fifteen years, and during the last two years had 
been so great as to interfere considerably with locomotion. The 
patient was first seen by Dr. Wilcox in February las-t, when she 
was suffering from peritonitis pretty generally distributed, and 
from acute nephritis due to diuretics administered by her physi- 
cian, who supposed her to be suffering from abdominal dropsy. 
There was no difficulty in making a diagnosis of tumor of the 
ovary. The nephritis subsided, and the peritonitis resulted in 
adhesions. Dr. Thomas performed ovariotomy. The larger 
tumor weighed a little more than forty-five pounds ; the others 
were small. The tube was adherent to the tumor, elongated 
and atrophied, the uterine extremity occluded ; there was dis- 
tension with a clear yellow fluid. The left ovary had also 
undergone cystic degeneration, and the tube was adherent to it. 

Thrombosis of the Left Coronary Artery ; Interstitial 
Myocarditis and Dilatation of the Heart.— Dr. J. F. Ridlon 
presented the heart, very much enlarged, with thrombosis of 
the left coronary artery, of a man about fifty-five years of age, 
who had for some years suffered from dyspeptic symptoms with 
an interval of apparent good health extending over some 
months. About noon, April 30th, having been in his usual 
health, he felt distress in the stomach, and soon afterward be- 
came faint and vomited. He was seen by several physicians 
during the course of the afternoon and night, and at one time 
was supposed to be dead, but revived. The pain and restless- 
ness were finally checked by a small hypodermic injection of 
Magendie's solution of morphine. The patient was able to walk 
to the fixed basin, which he insisted upon doing when com- 
pelled to vomit. At 7 a. m., May 1st, he seemed to be much 
better, but was found dead half an hour later. The most im- 
portant lesions found post mortem were, as stated, thrombosis 
of the left coronary artery, completely obstructing its caliber, 
marked enlargement of the heart with dilatation, interstitial 
myocarditis, and fatty degeneration; there was also enlarge- 
ment of the liver, spleen, and kidneys. The stomach appeared 
normal, but contained a few ounces of blood. 

Intra-meningeal Haemorrhage.— Dr. W. P. NoRTrmnp 
presented a microscopical slide, illustrating this condition. He 
also presented a 

Section of a Lung embedded in Celloidin.— After find- 
ing that the ordinary processes were inadequate for the prepa- 
ration of the entire lung for section, he placed the lung in a 
weak mixture of alcohol and water for some days, afterward in 
celloidin for a number of days, and finally again in alcohol. By 
this process he was enabled to make a complete section of the 
base of the lung. The section presented showed interstitial em- 
physema and in places pneumonic consolidation and infiltrated 
and dilated bronchi. 

Multiple Abdominal Tumor.— Dr. C. C. Lee presented the 
specimen, removed from a quadroon, twenty-six years of age, 
of delicate frame, emaciated, who had observed an enlargement 
of the abdomen said by several physicians who had seen her 
not to be due to pregnancy. Dr. Lee diagnosticated tumor of 



48 



PROCEEDINGS OF SOCIETIES. 



[N. Y. Med. Jouh., 



the ovary, although he had never seen a pure ovarian cyst in 
the negro race. At the operation the growth was found to in- 
volve the uterus, which was also removed. The tumor had 
probably begun as a tibro-cyst of the uterus which had under- 
gone colloid and partial cystic degeneration. At one point were 
found a few hairs and a slight osseous formation. The patient 
had shown no bad symptoms since the operation. 

Exsection of the Hip Joint.— Dr. L. H. Sayke presented 
the remains of the necrosed upper portion of the femur and 
detritus of the acetabulum removed by exsection in the case of 
a girl eight years of age, who had for some years suffered from 
hip disease. The trouble began with pain in the knee. Differ- 
ent forms of apparatus had been applied by physicians in Illi- 
nois, Missouri, and Kansas, and with varying degrees of success 
so far as relief from the symptoms was concerned. There was 
a phthisical history in the family, and this child was born pre- 
maturely between the seventh and eighth months. The opera- 
tion of exsection was done by Dr. Sayre the present month, and 
the child was doiDg well. 

MEDICAL SOCIETY OF THE COUNTY OF KINGS. 
Meeting of May 19, 1885. 
The President, Dr. J. A. MoCorkle, in the Chair ; 
Dr. Z. T. Emery, Secretary. 

Cholera Asiatica and Cholera Nostras ; their Diagnosis 
and Treatment, with Special Reference to the Bacillus.— 

Dr. Arnold Stub read a paper with this title. [See page 32.] 

Dr. Chase remarked that the author had stated that raising 
water to a high temperature would destroy cholera bacilli. 
Would the cooking of fruit, particularly apples, have the same 
effect ? 

Dr. Stub replied that he thought it certainly would, provid- 
ed that after the apples had been cooked they were not allowed 
to stand exposed. 

Dr. L. Barkan said that, having been deputed by the Aus- 
tro-Hungarian Government to treat cholera patients, he had 
had some experience with the disease. He had seen no benefit 
result from the use of opiates, but had had excellent success 
with sulphate of quinine. From a theoretical standpoint, he 
would oppose the use of hot baths, because the increase of tem- 
perature might be followed by a marked decrease, in accord- 
ance with Traube's theory. 

Dr. W. H. Thayer remarked that the paper covered so much 
ground that he was neither able nor inclined to examine it critic- 
ally throughout. One or two points, however, in the treatment 
of cholera appeared to him to be worthy of notice. He could 
not agree with Dr. Stub in his statement as to the effect of hot 
baths in the algid state of cholera. It was the experience of 
many physicians in several epidemics that the use of the hot 
bath was injurious and fatal to the patient. Dr. Parkes, an 
East Indian surgeon, who had published a very admirable re- 
port on cholera, after five years' experience in India, said pa- 
tients to whom a warm bath was given invariably came out of 
it colder than when they went in, and the disease was more 
rapidly fatal than if the bath had not been given. The speaker 
was confident that this had been the experience of physicians in 
other parts of the world, and it had been his experience in the 
epidemics of 1849 and 1866. A similar statement was made in 
the report of the Boston Cholera Hospital, in which, in 1849, 
they treated two hundred and fifty patients. Cold water had 
not only been more grateful to the patient, but it had had no 
unpleasant effects. Another point he wished to speak of was 
the use of opium, which Dr. Stub had advocated. In the speak- 
er's experience, and that of all others who had seen much of 



cholera, it had been found to be wholly inert after the establish- 
ment of the algid stage. Jt was universally employed in the 
management of the premonitory diarrhoea, and with great ad- 
vantage; but it must not hence be inferred that it was applica- 
ble to the algid stage. It was possible that its inefficacy was 
due to the failure of the stomach to absorh it, and that adminis- 
tered hypodermically, as Dr. Stub had recommended, it would 
have a favorable effect — but that was hypothetical. 

Dr. Stub replied that he had not mentioned opium in con- 
nection with any stages of the disease except as given hypoder- 
mically and in the algid stage, in combination with atropine. 
Opium internally would be of no use in any other form. With 
the exception of calomel, he would give no remedy by the 
mouth. As regarded the question of hot baths, he was not in 
the position to deny the statements of Dr. Thayer, in former 
epidemics, but he was of the opinion that, had he not given hot 
baths to the gentleman connected with the transatlantic steam- 
ship company, he would have died. The circulation was very 
low, and he could feel only the carotids. The radial pulse had 
ceased beating altogether. The baths instilled new life into 
him. The pulse became stronger, and he rallied. The speaker 
had. not the least doubt that the experience at Boston, as men- 
tioned by Dr. Thayer, was correct. He was aware and believed 
that different epidemics of cholera had different features. One 
epidemic could be managed by certain remedies, while another 
epidemic required different remedies. So it might be in the 
instances mentioned. He had had the same experience with 
yellow fever. In one epidemic a certain course of treatment 
would prove very efficient, but would fail, perhaps, in the next. 

Dr. R. G. Eooles stated that in some late investigations into 
the literature of disinfectants he had come across an analysis of the 
results of treatment as compared with non-treatment in a number 
of cholera outbreaks. Of the patients under medical care, fifty 
per cent, survived, and, of those left entirely alone, fifty per 
cent, survived. Among the numerous remedies recommended, 
the best results had been reported as coining from aqueous solu- 
tions of glycerite of tannin, injected as far as possible up into 
the bowels. One French physician had reported extraordinary 
success in using this remedy. It was less likely to produce in- 
jury than any other. The tannin was decomposed into glucose 
in the system, so that its products were harmless. It was alleged 
for this remedy that it destroyed the comma bacilli wherever it 
came in contact with them, and, by reducing their numbers, 
necessarily reduced the quantity of poison to which the danger- 
ous symptoms of the disease were due. If treatment had given 
no better results than non-treatment in the past, and this qr 
any other remedy could save a larger percentage, it would be a 
blessing to the race. The reader of the paper had said he could 
see no reason for expecting benefit from inoculation in cholera, 
since the disease was primarily local. The speaker thought 
that on a priori grounds the experiments were not only justi- 
fiable, but commendatory. While the comma bacilli were prob- 
ably primarily responsible for the disease, all the evil symptoms 
resulted from absorption into the blood of the ptomaines pro- 
duced by the micro-organisms. Persons who survived an attack 
did so because they could resist the paralyzing effects of these 
toxic agents. Inoculation, perhaps, accustomed the system to 
these poisons, thus establishing a tolerance like that of the mor- 
phine and alcohol habits. Such tolerance might constitute im- 
munity by giving the cells of the body an advantage over their 
foes, so that the germs could gain no habitat, and would fail to 
multiply. On the question of disinfectants he thought the 
essayist must have meant that chloride of calcium was almost 
useless, and not chloride of lime. The latest investigations had 
shown that good chloride of lime ranked next to corrosive sub- 
limate, both in cheapness and in value as a disinfectant. For 



July 11, 1885.J 



PROCEEDINGS OF SOCIETIES. 



49 



some purposes it was superior to everything else. It not only 
destroyed the comma bacilli, but quickly and effectually rid us 
of the most persistent spores known. But it must be good, 
the tests of which were dryness and solubility in water. If 
moist, it had too much chloride of calcium; if insoluble, too 
much lime. Where corrosive sublimate failed, it must take its 
place. In the dejections of patients, and in sputa, where there 
was likely to be albumin, mercuric chloride was worse than use- 
less. It coagulated the albumin, forming a protecting sheath, 
within which the germs were secure from harm. As to the 
connection between cholera asiatica and cholera nostras, he 
thought the weight of evidence pointed to their common origin. 
Continuity in disease would become pretty certain to such phy- 
sicians as kept their mental eyes open. In scarlet fever it had 
been observed that exposure sometimes produced symptoms so 
mild that but few would be bold enough to make a diagnosis. 
So far as the comma bacillus itself was concerned, the part it 
played in the disease was not yet certain. A case had been re- 
ported of a regiment of soldiers being attacked by cholera in 
their barracks. After many deaths had occurred they were 
ordered to tent out a short distance away. They drank the 
same water, ate the same food, and attended to the same duties, 
but the mere change of a few perches arrested the outbreak. 
If their soiled linen, water, hands, or anything else likely to 
convey micro-organisms had been responsible for the disease, 
why did it cease on mere change of locality? If Koch was 
right, while it was advisable for us to disinfect sewers now, it 
would be a fatal policy to pursue during an epidemic of cholera. 
We should thus kill the Bacterium termo, the natural enemy of 
the comma bacillus, and give the latter a better chance to mul- 
tiply. 

Dr. Stub wished to mention that tannic acid as an injection 
had been mentioned by him in his paper as having been very 
efficient during the last epidemic in France, but he would object 
to the use of glycerin because it could do no possible good, and 
might do much harm, for it might deplete the mucous mem- 
brane, when our aim should be to add water to the system, and 
not to deplete the blood still more. He also thought that Dr. 
Eccles's objection to the bichloride as a disinfectant because it 
coagulated the albumin might be overcome by the fact that it 
would kill the bacilli before it coagulated the albumin, and be- 
sides, in the speaker's opinion, the bacilli were albuminoid 
bodies themselves. 

(To be concluded.) 

BROOKLYN PATHOLOGICAL SOCIETY. 
Meeting of February IS, 1885. 
The President, Dr. B. F. Westbeook, in the Chair ; 
Dr. A. H. P. Letjf, Secretary. 

Necrosis of the Femur.— Dr. Justus E. Gregory presented 
a small sequestrum removed from the inner side of the middle 
third of the left femur at a point where the femoral artery lies 
nearest to the shaft of the bone. February 15, 1883, the pa- 
tient, a man aged forty-six years, consulted him in reference to 
a carbuncle situated over the left shoulder blade, which was 
treated by deep incisions. On the 20th of April he complained 
of a swelling on the front of the left thigh in its upper two 
thirds, which proved to be an abscess. This was freely laid 
open and search made for diseased bone or periostitis, neither 
of which was discovered. After thorough irrigation with bi- 
chloride solution (1 to 2,000), large drainage-tubes were intro- 
duced and the wound was packed with bichloride gauze. It 
healed by granulation. In February, 1884, the speaker's atten- 
tion was called to a sinus which had formed on the anterior 



surface of the thigh about its middle third and taken a course 
directly toward the femoral artery. From this sinus there was 
a slight discharge of pus, and, upon passing a probe, diseased 
bone was discovered. An operation for its removal was per- 
formed by Dr. Wackerhagen on February 5 th. Esmarch's 
bandage having been applied, alarge hand probe was introduced 
into the sinus and followed by incision up to the femoral artery. 
The opening was enlarged over the course of the vessel, and 
when the latter was reached it was separated from the bone by 
retractors, as it actually covered the cloaca. This was enlarged 
and several small sequestra were removed. The patient recov- 
ered, with a perfectly useful limb. 

Dr. Kretzschmar desired to know how periostitis could be 
diagnosticated by simple incision of an abscess. 

Dr. Wackerhagen said he had believed at the time that the 
abscess was due to bone disease, and if he was right it could be 
better ascertained by the opening of the cavity. 

The President remarked that periosteal abscess of the fe- 
mur was usually so deep that it was hard to find; the abscess 
in this case was superficial, and so out of the usual course. 

Dr. Kretzschmar rejoined that he still failed to see how 
simply opening the cavity would enable one to make the diag- 
nosis. 

Dr. Wackerhagen replied that the abscess was diffuse and 
had to be opened to let out the pus, and he took advantage of 
that fact to probe for any of the bone that might be diseased. 

Self-mutilation by Amputation of the Genitals.— Dr. H. 
D. Bliss gave the history of a case he had seen during the sum- 
mer in the practice of his friend, Dr. J. H. Taylor, of Mount 
Holly, N. J. A farmer became affected mentally after the death 
of his wife. He grieved much at the loss of his wife, and, as 
the neighbors afterward said, acted somewhat queer at times, but 
continued his work as usual. One morning he was found with 
his scrotum and penis amputated. The reason, as he explained 
the next day, was that he had felt impelled to do it, for, as he 
had been the cause of bis wife's death, he thought this would be a 
relief; so, taking a razor, he had taken the entire external geni- 
tals in the left hand, pulled them well out and up, and, with one 
cut of the razor, severed the entire organs. They were afterward 
found well connected together. He was not discovered for 
some time, and it was several hours before the medical attend- 
ant arrived. The haamorrhage, which had not been very con- 
siderable, had nearly stopped, except a slight welling up around 
the urethra, probably from the dorsal arteries of the penis. 
This was slight, but continued troublesome for several days on 
account of the difficulty of securing the vessels which lay in 
close contact with the urethra. It could be stopped with serre- 
Jines, but it would begin again every time a catheter was passed. 
It was finally stopped by applying compound tincture of ben- 
zoin. The cut with the razor had exposed the pyramidalis 
muscle and removed the skin over the pubes, making a wound 
that could scarcely be covered by the palm of the hand. It was 
at first intended to dress it with carbolized water, but the nurse 
allowed it to dry so often that a cloth dipped in carbolized oil 
was kept over the parts, and the man made a good recovery. 
The penis being put on the stretch at the time of the cut, the 
urethra retracted about three fourths of an inch below the 
surrounding tissue, and there was trouble in keeping it from 
closing. Catheters of various kinds were tried — silver, rubber, 
flexible, non-irritant, etc. — but all proved so irritating they had 
to be discontinued and some other means resorted to. On 
December 27th Dr. Taylor made a cut an inch and a half down 
the perinceum, dissected up the skin, and trimmed the tissue so 
that the integument could be stitched to the urethra. This was 
done, and all closed with silver wire, and in one week, as the 
doctor said, "ho had a good working urethra." 



50 



PROCEEDINGS OF SOCIETIES. 



[N. Y. Med. Jour., 



Among the points of interest in the case were the recovery 
from the delirium, the speedy recovery of the patient, and the 
small amount of hajmorrhage from so vascular a structure. 

The President related a similar case that had occurred in 
the Eastern District some years ago, in which the victim's para- 
mour cut off his genitals with a razor, causing fatal hajmor- 
rhage. 

A Case of Hysterectomy for Cancer was then related by 
Dr. W. C. Burke, -Jr., of South Norwalk, Conn. [It has already 
been published.] 

Dr. A. H. P. Leuf remarked that he fully coincided with 
Dr. Burke in considering carcinoma at first local, and thought 
that thorough eradication of the disease in loco, with the extir- 
pation of the first set of lymphatic glands and intermediate 
lymph-vessels in all cases, as an additional safeguard, would be 
followed by satisfactory results, if done in time. Many lives, 
he thought, were sacrificed because of a great lack of fearless 
and intelligent surgery. 

Dr. R. G. Eccles desired to know if any embryologist was 
present to tell the society about the transition of embryonic 
cells into pathological cells. 

Dr. C. N. D. Jones said that the case just brought before us 
was another one in favor of the operation. 

The President remarked that many of these growths were 
at first local and benign, and afterw r ard became malignant. 
This was especially true of the skin, for moles and other benign 
affections of the integument sometimes, and perhaps in the ex- 
perience of many present, became malignant. A case had oc- 
curred in his experience about one year ago. The patient was 
a lady who had a " mother's mark " two inches below Poupart's 
ligament. He did not see it at the beginning, but believed it 
was a mole, and not a naevus. Subsequently, when she had 
been sewing with a machine, the irritation due to the friction 
of her clothing while at work was painful, and caused bleeding. 
When seen by him, the lesion looked like an excoriation, and it 
was not raised more above the general surface than was usual 
in moles. There was no perceptible involvement of the gland--. 
He ordered an ointment. Six months later the patient returned 
with the sore much worse, painful, bleeding freely, and emitting 
a very offensive odor. He found a projecting mass about an 
inch and a half in diameter and fully half an inch high. It 
had the general appearance of a malignant growth. He re- 
moved the whole mass at St. Mary's Hospital. Everything was 
extirpated down to-the cribriform fascia, and the fascia lata 
scraped for several inches around the original sore. Several 
affected glands were removed at the same time. A few days 
later one of the Sisters at the hospital called his attention to a 
lump over the patient's iliac crest. There seemed to be no con- 
nection between this lump and the wound. Two weeks later 
these nodules developed over the whole body, and a few months 
after the operation she died in horrible agony. It was hard to 
account for the malignancy of this case by the accepted views of 
cancer genesis. Paget's case of cancer at the outer side of the 
thigh was referred to. The same was true of the female breast. 
It was notoriously difficult to differentiate between benign and 
malignant growths. As regarded Dr. Eccles's question, he would 
say that it had been, and by many was still, maintained that all 
cancerous growths were developed from the cells of the inter- 
mediate layer of the embryo. Cohnheim had asserted that all 
cancers were congenital. The whole being was abnormal from 
the on-et, and only required an irritation to start the malignant 
processes. The outer and inner layers of the embryo had be- 
tween them undeveloped cells, which, by subsequent irritation, 
became developed into malignant structures. Thus we met 
with most of these formations in the uterus, gullet, etc. Cohn- 
heim's views were opposed to those of Dr. Burke and others. 



These latter gentlemen make it local, while the former would 
have it general. 

Dr. Ecci.es wished to know if Cohnheim's views could not 
be reconciled with those of the other gentlemen by supposing 
the irritation to extend after the local disease had existed for a 
sufficient length of time. 

The President replied that Cohnheim supposed that some 
of the cells in many people had not properly developed, and 
that it was at such places that cancer began. 

Dr. Ecoi.es reiterated the question, whether these cells 
passed through several stages or at once became cancerous. 

The President replied that in embryonic life they became 
differentiated by a comparatively immediate transition. 

Dr. Andrew Otterson had seen a bad case of "cancer" 
which, after excision, turned out not to be cancer. It was not 
always easy to make a diagnosis, and more especially a progno- 
sis. Of about twelve patients upon whom he had operated, 
only two had survived for five years. In one the tumor had 
been said to be certainly very malignant and in the other doubt- 
ful. A former librarian of the Brooklyn Library, fifty years of 
age, was on a step-ladder, and, while reaching up, fell and struck 
his breast. It troubled him a good deal. He was under the 
care of a good surgeon, and was advised to have a resulting 
lump cut out. Some told him not to have it done. Eventually 
the speaker cut it out. It came back again in the cicatrix 
within a year, also involving some of the neighboring parts. 
No glands appeared to be affected. It was again excised, and 
again returned in two years and involved the body generally, 
but more especially the spinal cord and other parts of the nerv- 
ous system, as shown by post mortem examination. Another 
case was that of an old woman in Fulton Market. A boy struck 
her in the breast with a stone. The resulting nodule remained 
for years. At last it began to suppurate, and all the neighbor- 
ing glands were involved. Yet another case was that of a jani- 
tor with a nodule of the size of a walnut on the shin from a fall 
off a step-ladder. It became a suppurating and bleeding sore. 
The stench was as bad as it could possibly be. The part was 
very painful. The speaker removed the whole mass with a 
ligature, and there never had been any return. The man lived 
for many years, and died of a totally different trouble. He had 
been sure that this was a case of malignant disease. He be- 
lieved every practitioner could relate similar cases. As to the 
indiscriminate removal of all nodules, he thought it impracti- 
cable because of the objections on the part of patients. 

Dr. Burke said that, as to the justifiability of hysterectomy, 
he was sure that a large proportion of patients would be saved, 
if surgically treated before it was too late. He had seen an 
operation two days after bis, but the case was so far gone that 
the patient did not live. There was no peritonitis, but death 
was due to asthenia. In such advanced cases the operation 
was not justifiable, but it was if done early and when the dis- 
ease is local. He thought the operation would become more 
popular. 

Comminuted and Depressed Fracture of the Skull; 
Trephining ; Fungus of the Dura Mater ; Recovery. — Dr. 

Burke then read a paper with this title. [See page 36.] 

Dr. R. G. Eccles asked if there had been other psychologi- 
cal effects noticed than those that had been mentioned, for the 
piece of bone driven into the brain must have entered at about 
the speech center. 

Dr. Burke replied that there had been no such symptoms. 

Dr. Eocles: " Has he lost any words? " 

Dr. Burke: "No." 

Dr. A. Ross Matiieson related a case. A piece of frontal 
and temporal bone about an inch and a half in diameter was 
driven into the brain by a horse's kick. Fissuring extended 



July 11, 1885.J 



PROCEEDINGS 



OF SOCIETIES. 



51 



completely across the frontal bone. The upper fragment over- 
lapped the lower fragment. Considerable brain-substance was 
lost. The case was also seen by Dr. Daniel Ay res, Dr. George 
K. Smith, and Dr. H. Messenger Ayres. Those parts of the 
bone that had been driven into the brain were removed. Dr. 
Smith desired to correct the position of the overlapping frag- 
ments, but, Dr. Ayres and the speaker objecting, they remained. 
There was complete paralysis. Two weeks later a fungus duras 
matris developed. It grew as large as the one in Dr. Burke's 
case. He could not get rid of it by shaving it off a number of 
times. At last it was sprinkled with sulphate of copper, and a 
rubber compress was applied. Then it soon healed. At pres- 
ent the patient was well and was an operator in a stock office 
in Wall Street, New York. The overlapping in the frontal re- 
gion no longer existed, and in its place could be seen a line of 
pulsation, half an inch wide, extending all the way across the 
forehead. He continued a little aphasic for about six weeks 
after getting up. Now, however, he had no physical or mental 
symptoms whatever. 

Dr. Ecoles called attention to the fact that, according to 
phrenologists, the patient ought to have lost the sense of atten- 
tion after losing so much cerebral substance from such a local- 
ity. 

Dr. Matiieson stated that the loss of brain substance had 
amounted to two or three ounces. 

Dr. JosEPn H. Hunt desired to know if the opening in the 
skull in Dr. Burke's case had been filled in by new bone. 

Dr. Burke replied that it had not, and that at present it was 
only covered with membrane and skin. During quiescence the 
skin was sunken in, but when the patient became excited it 
bulged out. 

Dr. Hunt said he had been unusually interested, as he had 
had a similar case some years ago. The skull was fractured at 
the vertex and the fragment depressed about an inch. It was 
removed by Dr. Jar vis S. Wight. The boy was quite well now. 
There was no fungus duras matris. The scar looked almost like 
a fontanelle. 

Dr. Leuf remarked that he had seen Dr. Hunt's patient not 
very long ago and had taken occasion to make some inquiries. 
He was now a vigorous, healthy, and active young man, en- 
gaged in rather hard work. Since the recovery from the injury 
he had become irascible and rather quick-tempered, qualities 
diametrically opposed to those he bad exhibited previous to the 
receipt of the injury. The opening was now quite small and 
triangular in outline. Pressure upon this opening caused the 
patient to experience a sickish sensation, and, if it was increased, 
he felt a gradual onset of insensibility. Further than this, he 
was afraid to have the experiment tried.* 

The President remarked that in Dr. Burke's case the motor 
regions had been involved according to Ferrier and Rolando. 
Brown- Sequard held that, if one side was injured and its func- 
tions were abolished, the other side would assume them in addi- 
tion to its own. Dr. Burke's case seemed to be a demonstration 
of the latter view. 

Dr. Burke replied that the case had struck him as being so 
unusual that he had closely observed it from the beginning, but 

* Note by Dr. Leuf. — Because of the interest attached to this case, 
1 would mention another fact. Since the meeting of the society the 
opportunity presented itself to me to sail in a yacht (less than ten days 
previous to this writing), which was solely managed by Dr. Hunt's former 
patient. It was done with skill, after a whole morning and early after- 
noon's hard work of rigging up for the first trip of the season. The 
sail was such that it required no ordinary amount of skill, care, and in- 
genuity to get along without mishaps, of which latter we had no expe- 
rience whatever. This in addition to the above-noted facts connected 
with the after-effects of loss of brain-substance. 



could not say that he had noticed anything in addition to what 
had already been stated. 

Dr. Otterson mentioned a case that he had had in which 
the brain oozed away for years. Afterward the patient became 
a conductor on a railway car. His intellect was not in the least 
impaired. He had never had any unpleasant symptoms of any 
kind. 

OBSTETRICAL SOCIETY OF PHILADELPHIA. 

Meeting of June 4, 1885. 
[Continued from, page 24.) 

Gestation in a Sarcomatous Uterus simulating Extra- 
uterine Pregnancy. — Dr. Bernardy related the following 
case: On the 3d of October, 1884, he was requested to visit 
Mrs. McG., a delicate woman, about thirty years old, whom he 
found suffering with double pneumonia. At the same time he 
was told that she was five months pregnant. The abdomen 
was rather large for that period. On the 5th she complained 
of a sharp pain in the right inguinal region, which required 
large doses of morphine before any relief was obtained. He 
found the right inguinal region filled by an immense growth 
reaching almost to the lower border of the liver. The uterus, 
or what appeared to be the uterus, was enlarged and pushed 
well toward the left side. The right side of the pelvis was filled 
by a growth. At first he thought he detected fluctuation, but 
closer examination showed the growth to be hard to the touch. 
The uterus was immovable, the neck being somewhat absorbed 
and the os tilted up behind the pubes. To reach it, the finger 
had to be passed well upward ; it was closed and soft. The 
patient had never had any uterine trouble. The menses had 
never appeared after her marriage, which occurred one week 
after a period. Her health remained good for three months 
after marriage, when, while out walking, she was suddenly 
seized with a sharp lancinating pain in the right side of the 
abdomen. The pain was so great that she almost fainted, bnt 
finally reached home and went to bed. No physician was called 
in. The next day there were slight traces of blood on her night- 
dress. Under absolute rest the pain subsided, and at the end 
of a week she was about her household duties. The pain in 
the side returned if she exerted herself. Sexual intercourse 
was painful and was followed by traces of blood the next day. 
Believing that the symptoms pointed to either extra-uterine 
pregnancy or a tumor complicating pregnancy, he asked Dr. 
Goodell to meet him. By the time the consultation was held, 
on the 8th, a severe attack of peritonitis had begun. A close 
examination was therefore impossible. On account of the dis- 
tended and painful condition of the abdomen, the outline of the 
growth or uterus could not be traced. It was decided that 
the symptoms and history pointed to extra-uterine pregnancy, 
but, whether the uterus contained a tumor or a child, in the 
present condition of the patient it was impossible to decide. 
By the 16th the peritonitis was under control, but the lungs 
were no better. On the 19th he was sent for, the messenger 
stating that there was a renewal of the peritonitis. He found 
the patient in active labor, the foetus descending rapidly. In 
half an hour labor was completed. He readily detected the 
large growth filling the upper portion of the right side of the 
pelvis; the uterus was surrounded by a hard growth. The 
cervix was hard. From this time the lungs improved, but the 
patient remained extremely weak and there was a constant 
dribbling of blood from the vagina. November 3d, the growth 
was still present and the cervix hard, and he began to think of 
malignant disease in connection with the tumor. He had ap- 
plied to the abdomen, night and morning, an ointment of mer- 
curial ointment, belladonna, and iodine, which seemingly had 



52 



PROCEEDINGS OF SOCIETIES. 



[N. Y. Med. Jonn., 



the effect of causing the absorption of the large growth, but the 
mass surrounding the uterus remained the same. On the 27th 
vomiting occurred and was arrested with difficulty ; there was 
a bloody discharge from the vagina and a constant sore feeling 
over the region of the uterus, which was still toward the left 
side. The patient was extremely weak ; the slightest exertion 
exhausted her and brought on bleeding from the uterus. De- 
cember 26th lie found her suffering from pleurisy, the left pleu- 
ral cavity being full of fluid. January 1st abdominal dropsy 
had set in. A consultation with Dr. Goodell was held, and a 
positive diagnosis of malignant disease was made. It was 
thought that death might occur at any moment, and she died 
suddenly the same evening. 

The post-mortem examination, by Dr. E. A. Russell, showed 
the entire abdominal cavity greatly distended with a dark fluid 
full of broken-down lymph. The intestines were forced upward. 
There were slight evidences of beginning peritonitis. A por- 
tion of the ileum on the right side presented a black, unhealthy 
appearance bordering on gangrene. The uterus was increased 
in size. The outer surface presented an irregular mottled ap- 
pearance, and large veins covered its surface. At the fundus 
there appeared a spot, about one inch in diameter, of a bluish 
tinge. On pressure by the finger the surface readily broke, and 
underneath was a cavity, of about the size of a large hickory- 
nut, which did not communicate with the interior of the uterus. 
The cavity of the uterus was found to be almost obliterated ; 
the tumor seemed to have entirely absorbed the true uterine 
tissue with the exception of the neck. In the body of the 
tumor were observed small masses or growths varying in size 
up to that of an egg. The ovaries were small and seemed to 
have participated in the general disease. Microscopic examina- 
tion proved the tumor to be an adeno-sarcotna. 

At first the speaker had been convinced that he had a case 
of extra-uterine pregnancy ; but the peculiar hardness of the 
tumor made him doubtful. Here was a patient that had never 
had any uterine ailment, who married, became pregnant, at the 
end of the third month, without any premonition ; while quietly 
walking, was seized with pain of an excruciating nature in the 
right side, went to bed and remained quiet, and the next day 
blood flowed from the vagina. She remained comparatively 
■well for two months and a half more, when she was again sud- 
denly seized with pain in the same side, followed by peritonitis. 
A tumor was found in the affected side; the uterus was en- 
larged, but not sufficiently so for a five and a half months' preg- 
nancy, the os giving no signs of that softening which should 
accompany pregnancy. Could we have a group of symptoms 
more allied to those of extra-uterine pregnancy? 

Infant Feeding.— Dr. J. M. Keating said that, at his re- 
quest, Dr. Charles Potts had instituted a series of experiments 
which had a decided practical value, and they hoped to present 
them to the society at an early date. He desired to place on 
record a statement of the results so far reached, which appeared 
to be interesting and important. The question often arose, Was 
it of advantage or not for an infant to be partly nursed and 
partly bottle-fed? What action had milk upon starch, if any? 
To answer this the following tests were made: 1. A sample of 
milk composed of the milk of several women, contained, ac- 
cording to a quantitative estimation by Fehling's method, 6 - 84 
per cent, of sugar. Ten c. cm. of this milk were then taken, f 
gramme of powdered starch was added, and the mixture was 
allowed to stand at a temperature of 99° F. for thirty minutes, 
after which 5 c. cm. diluted with 45 c. cm. of distilled water, were 
tested and showed 8-62 per cent, of sugar. The other 5 c. cm., 
after standing sixty minutes, gave 9 - 09 per cent. 2. Another 
sample, found to contain 7 - 14 per cent, of sugar, had % gramme 
of powdered starcli added as in No. 1. In thirty minutes it gave 



9 - 803 per cent, of sugar in 5 c. cm. The other 5 c. cm., after 
remaining sixty minutes, gave 8 - 62 per cent. Possibly part 
of the sugar deposited was drawn off with the first 5 c. cm. 
3. Another sample showed 6-32 per cent, of sugar, and, after 
the addition of starch as before, gave in the first 5 c. cm. 8*19 
per ceut., and in the next 5 c. cm. 7'93 per cent. These inves- 
tigations showed that the women's milk gave an increase of 
sugar after digesting with starch. 4. A sample of cow's milk 
was tested and found to contain 3 - 87 per cent, of sugar. To 
this was added £ gramme of starch to 10 c. cm. At the end of 
thirty minutes 5 c. cm., diluted with 45 c. cm. of distilled water, 
showed no increase of sugar. 5. A sample of cow's milk gave 

4 per cent, of sugar, and was treated as before, but at the end 
of thirty minutes, and then sixty minutes, it gave the same 
result. G. Another sample of cow's milk gave 3 - 703 per cent, 
of sugar. It was treated as before, with the same amount of 
starcli. In thirty minutes 5 c. cm. gave the same result ; in sixty 
minutes 5 c. cm. gave the same result. These investigations 
showed that cow's milk gave no increase of sugar after the addi- 
tion of starch. Did the acidity of cow's milk prevent the 
sugar change? Did the sugar change continue in an acid me- 
dium? 7. Another sample of human milk — from one woman 
— yielded 6 - 25 per cent, of sugar. Starch was added as before. 
In thirty minutes 5 c. cm. gave 7 - 14, and in sixty minutes 5 c. cm. 
gave 7*6 per cent, of sugar. To 10 c. cm. of this milk (contain- 
ing fi - 25 per cent, of sugar) a few drops of dilute hydrochloric 
acid, enough to faintly acidulate it, were added, and then i 
gramme of starch, and it was allowed to stand as before. In 
thirty minutes 5 c. cm. gave 6"41 per cent., and in sixty minutes 

5 c. cm. gave 7*35 per cent, of sugar. 8. Another sample of 
woman's milk without starch gave 6"17 per cent., with starch 
7 24 per cent. Ten c. cm. of the same, acidulated with hydro- 
chloric acid, diluted, gave in thirty minutes 7*35 per cent. In 
these tests 10 c. cm. of Fehling's solution were used with 40 c. cm. 
of distilled water. If future investigations proved the correct- 
ness of these statements, we might safely assert that the nurs- 
ing woman might advantageously supplement her breast milk 
with some well-prepared digestible form of food containing a 
small quantity of starch, and also that the anxiolytic ferment 
would remain active in the slightly acid stomach of the infant. 

The Surgical Treatment of Infants.— By invitation, Dr. 
DeForeest Wiixakd read the following paper: 

Your committee having invited me to speak to you to-night 
upon the surgical treatment of infants, I purpose to confine my 
remarks chiefly to personal experiences in the means of reliev- 
ing the principal surgical difficulties which are met with during 
the first two years of life. If the subject shall occasionally lead 
me to mention older children, it will be because the line be- 
tween infancy and childhood is not a marked and well-defined 
one. As you are all active practitioners also, it will be unne- 
cessary for me to dwell upon detail, and I shall only touch upon 
practical points in treatment. 

The surgery of childhood, as compared with that of adult 
life, is, aside even from congenital defects, sufficiently marked 
and distinctive to entitle it to separate consideration. First of 
all must the children's surgeon acquaint himself with the anato- 
my of the child. This is rarely done, as the ordinary adult dis- 
sections during a college course give little idea of the size and 
position of the individual elements as seen in the infant. In 
consequence of ignorance upon this practical point many griev- 
ous failures have occurred. After unusually large opportunities 
for the study of both normal and abnormal tissues in the diminu- 
tive frame, I am still frequently surprised to note the exceeding 
smallness of different organs and canals. 

Another essential element in the surgeon is tact in the man- 
agement of the little ones, especially when dealing with those 



July 11, 1885.1 



PROCEEDINGS OF SOCIETIES. 



53 



betweenthe ages of two and ten. In hospital cases but little 
history is attainable, and much depends upon quick perception. 
Naturally fearful of pain, the patient's mind must be diverted 
and engaged, or great difficulties in diagnosis will often occur 
from the fright and struggling. The operator not in sympathy 
with children can never secure their confidence. Much will 
often be gained by quiet observation. It is not a month since 
my opinion, which at the first few moments of the consultation 
had been favorable to tracheotomy, was changed by five min- 
utes' close watching, and the result proved the correctness of 
the procedure. To the person, however, who will carefully 
study individuality as well as disease, no department of medi- 
cine offers so pleasant a return for his labors. My personal 
experience with children has perhaps made me more hopeful in 
regard to the power of such individuals to endure pain, shock, 
and disease, than would be indicated by the expressions of other 
authors, but to me there is no domain of surgery so attractive 
and gratifying as the treatment of children below the age of 
puberty. Their natural condition is that of hopefulness, and, as 
soon as the depressing influence of shock, pain, or fear is re- 
moved, the normal resiliency of mind and body asserts itself 
with such rapidity that the results are often surprising. 

Again, a child has only inherited taints of constitution to 
contend against; his viscera are ordinarily in a healthy condi- 
tion ; an adult has not only hereditary but all the acquired vices 
occasioned by misuse or abuse of any organ or sets of organs, a 
circumstance which often turns the scale in the struggle between 
life and death. Take, for example, the single instance of the 
outraging of tissues by either the moderate or the excessive use 
of alcohol, and every surgeon will testify that even slight 
wounds may, in such an individual, quickly develop a fatal at- 
tack of mania a potu. Tetanus is not more frequent in infants 
than in adults, notwithstanding the tendency of the former to 
nerve excitability. 

In regard to anaesthetics, my experience is that great benefit 
is obtained by the use of ether when pain can thereby be pre- 
vented. In the first weeks of existence I admit that a feeble 
vitality would contra-indicate its use, although I have success- 
fully administered it to an infant three days old. After the first 
or second month, I see no reason why we should needlessly in- 
flict pain upon an infant simply because we can control it by 
brute force. In the examination of fractures great suffering is 
often inflicted by careless and frequent manipulation, and, unless 
the diagnosis is easy and positive, unconsciousness should be 
produced. No case of boue injury should ever be passed by 
undiagnosticated when ether will solve the question. In the 
opening of abscesses the " primary quieting influence " of ether 
is so readily obtained that it should be brought into use when- 
ever practicable, as keenness of pain can thereby be avoided. 

Fear plays an important part, aDd may depress the child's 
system even more than pain ; hence great caution should be ob- 
served that all knowledge of any operative procedure should be 
guarded against. When the day for action arrives, let the sur- 
geon quietly and gently state to the little one, if it has arrived 
at years of reason, just what it is proposed to do, at the same 
time assuring him that no pain will be experienced, and, if such 
words are followed by firm, speedy, and judicious management, 
much agitation and fear will be avoided. All preparations 
should be made out of sight and hearing of the patient, and in- 
struments need never be seen by him, except when a strong 
impression is intended to be made upon the mind of a mastur- 
bating boy requiring circumcision, in which case ether may 
also be omitted. 

One word in regard to the method of anaesthetization. It 
is but natural that a child should be distrustful of any attempt 
to deprive him of consciousness, a fear which is greatly in- 



creased by the injudicious and greatly-to-be-condemned habit 
of many parents, who systematically threaten their offspring 
with the expression, " The doctor will come and cut your head 
off." A few kind words will often quiet the agitation, and 
simple directions as to the method of breathing will save many 
minutes of struggling resistance. With very young children, 
the first smell of ether may be masked by permitting them to 
see cologne poured upon the towel, after which ether may be 
quietly added, and they will feel that it is a perfume that they 
are breathing. This device has frequently served me a good 
purpose. I always allow a good admixture of fresh air for the 
first moment, but, when the child actually begins to cry, then 
quick action answers best. The towel should now be well satu- 
rated and held firmly over nose and mouth until two or three 
strong screams and inhalations yield a full primary impression, 
which can be gradually followed up to complete anaesthesia 
with safety. 

Should any symptoms of ether narcosis occur, it is so easy 
to depress the head of a child, or to perform artificial respira- 
tion by acting upon the ribs, that serious accidents are infre- 
quent. Subsequent vomiting is very common but is not 
persistent, and is easily quieted by a small hypodermic of 
morphine, a procedure which ordinarily brings quiet sleep to 
the patient. If the child is feeble, I always allow milk up to 
within two or three hours of the operation, and then adminis- 
ter wine or whisky in water immediately before giving the 
anaesthetic. Milk with lime-water and whisky is usually re- 
tained within ten minutes after the first vomiting on rousing. 
In tedious excisions, not only should preliminary precautions be 
taken to secure against prostration by shock, but hot- water 
bags should be ready for use, which, with hypodermics of 
brandy, may succeed in tiding over a temporary depression 
which would otherwise end in death. When the loss of blood 
has been great, especially in acute surgery, important assistance 
may be gained by transfusion, either of blood or of a warm 
saline solution. 

Under the head of arrest of haemorrhage I would strongly 
advocate the use of animal ligatures, since the pain often inci- 
dent upon the removal of threads greatly disturbs the needed 
quietude of wound and mind. 

Thorough asepsis and antisepsis are especially valuable 
since we not only secure the admirable results that are attain- 
able by their use, but are also enabled to disturb the child with 
far less frequency. I am now treating a girl with a railroad 
crush of the leg which would thoroughly have justified amputa- 
tion, yet which, under corrosive-sublimate dressings, has been 
touched but six times in as many weeks, even though extensive 
sloughing has occurred. Save upon one occasion, at the height 
of the process of tissue-death, the applications have been taken 
away perfectly sweet, and the child has the promise of a reason- 
ably good limb. In my septic days I certainly was never able to 
carry a patient through such a process and keep the tempera- 
ture, as has been done in this case, below 99o° F. all the time, 
and usually but slightly above 98°. With infrequent dressings, 
the irritation of the child is but slight, and, if pain is also ab- 
sent, contentment is the rule, under proper nursing. 

I can not too strongly emphasize the importance of this lat- 
ter condition. A kind, quiet, gentle nurse is one of the most 
valuable assistants in the real progress of the case, especially 
during the first week following an operation. Such care can 
not be delegated to untrained and careless people, hence it is 
absolutely necessary that children should be in separate hospi- 
tals, or in separate wards, under the be3t of care-takers. Even 
in private practice the mother is rarely the best nurse for a 
child past two or three years of age, and a skilled attendant 
answers best. In hospital practice I have often been surprised 



54 



PROCEEDINGS OF SOCIETIES. 



[N. Y. Med. Joub.,, 



to see how contented and patient the majority of children of 
even three years of age will become if the mother maintains a 
judicious absence and the nurse is efficient and kind. 

Another point which I wish most emphatically to emphasize 
to-night is the fact that congenital defects are most inexcusably 
and persistently neglected by even good practitioners, under 
the mistaken opinion either that nothing can be done, or that a 
later period will be early enough. The consequence is that 
many unfortunates become helpless and hopeless cripples by 
their physicians' advice, since, passing out of his sight and mind, 
the neglect engendered by his direction, " wait," is fostered by 
parents, ever ready to postpone a dreaded day. 

Turning to some of the special surgical diseases of infants, I 
would say that it is my intention to simply touch upon a few 
points of treatment without regard to definite arrangement or 
order, since to consider almost any one of the conditions in full 
would require an entire evening's discussion. 

In a new-born child the first most probable trouble requir- 
ing surgical relief will be imperforate anus or rectum. Such a 
condition is not improbable when we remember that the intes- 
tine is formed as a closed tube. If the malformation is simply 
one of occlusion of the anus by a membrane, it would seem to 
be the easiest of procedures for any practitioner to make an 
opening, yet I have seen children permitted to die with the 
entire ischio-rectal fossa and perinseum bulging with retained 
fasces, when a simple puncture through a membrane closing an 
otherwise normal anus would have given immediate relief. This 
timidity may perhaps be explained by the fact that occluded 
anus and imperforate anus are confounded with imperforate 
rectum and the case is given up as hopeless. In imperforate 
anus the operation is still a simple one, since a crucial incision, 
together with stitching of the mucous membrane to the skin 
and subsequent dilatation with the finger or probe, is all that is 
required. 

When the anus is normal and patulous, but the rectum is 
occluded by a membrane, or is actually absent, a much more 
serious condition presents itself, the difficulty increasing in pro- 
portion to the extent of the deficiency. Should no meconium 
be passed within the first twenty-four hours, a careful search 
should be instituted. The little finger or a catheter passed into 
the anus will detect the obstruction, or, if the anus is absent, 
the vagina, if present, may be explored for abnormal fistulas. 
As soon as the presence of faces can be discovered in the fossa, 
a careful dissection should be made, keeping well backward, so 
as to avoid the vagina, or the urethra and bladder. A catheter 
should always mark the position of the urethra. There is but 
little danger, even in deep incisions, if the region of the coccyx 
and sacrum is followed. The gut found, it should be drawn 
down as far as possible and secured, a channel being maintained 
through the lower rectal region, if necessary, by the finger or 
by bougies, the latter of which should not, however, be retained 
constantly in position. There is much less danger from subse- 
quent haemorrhage if the external incision is free, and no fear 
need be entertained about the ultimate retention of fasces, as, if 
the child escapes peritonitis and other inflammations, good con- 
trol of the bowel is always secured ; in fact, the chief subsequent 
danger lies in the formation of stricture. When the length of 
the bowel will not permit it to reach to the site of the anus, the 
new opening may be made nearer to the sacrum. Should no 
trace of the rectum be found within two inches of the anus, it 
is unsafe to further explore a region where the peritonaeum 
would be liable to injury ; either left inguinal or left lumbar 
colotomy should be performed. The right groin is to be selected 
if there are evidences of absence of the sigmoid flexure. The 
left inguinal position gives a better subsequent opportunity of 
passing a bougie downward into the rectum and thus establish- 



ing a proper anus. If the colon is full, it will not be difficult to 
find. In cases of doubt, its distension by air or water through 
a hypodermic needle would determine its termination. Abnor- 
mal openings into the vagina, bladder, or urethra rarely require 
early operation, but, in non-retention of fasces at a later age, 
Iiizzoli's plan of procedure is a good one. 

Later in childhood, the surgeon is often compelled to treat 
another condition of the rectum, namely, prolapse. This, if 
excessive and non-yielding to replacement, astringent applica- 
tions, hot water bathings, and general constitutional measures, 
must be cured by the production of linear eschars by nitric 
acid. 

The genito-urinary organs may also require attention imme- 
diately after birth. A simple occluded urethra is easily relieved 
by the careful introduction of a sound or catheter. Epispadias^ 
hypospadias, and exstrophy of the Madder should not be allowed 
to go on to adult life without relief. As soon as the child has 
passed its dentition period, a plastic operation should be at- 
tempted for relief, since the mental and moral effect of such a 
deformity has often a marked influence upon the lives of the 
unfortunates. Adhesion of the vulva or nymphm should not be 
overlooked, since not only does the nervous system suffer, but 
the parts may be improperly developed. Separation can almost 
always be accomplished by the finger or by a probe. An abso- 
lutely imperforate hymen should never be allowed to exist if 
discovered, since, if permitted to impede the menstrual flow, at 
a later period, serious and even fatal results may follow its di- 
vision, if the uterus and Fallopian tubes have become dilated by 
the imprisoned secretion. Imperforate vagina should receive 
at least careful diagnostic attention to detect the presence of a 
uterus, and, if this is not absent, fuller development will be 
secured if the passage can he opened during the first few years 
of life. With a catheter in the urethra and a finger in the 
rectum, a careful operator can explore safely. I have met with 
several cases in which the penis was preternaturally short and 
ill formed, the body of the organ, during flaccidity, being almost 
entirely concealed in the fatty tissues of the pubes. *In such 
instances I have removed the prepuce during the first three 
months of life, and have cut away all restricting bands of skin 
and connective tissue, sometimes even drawing beneath the 
penis an extra flap of skin when the corpus spongiosum has been 
short and dwarfed. By such means the fullest amouDt of 
growth is encouraged. 

Adherent and contracted prepuce, or phimosis, has been the 
subject of much discussion in regard to its causal influence upon 
certain nervous manifestations. My views upon this subject 
have been already published,* and, after two years of additional 
experience, during which time I have been brought daily in 
contact with this class of cases, I can reiterate what I then 
stated, Damely, that, while more or less adhesion is an almost 
constant and normal condition, yet, when urinary, choreic, 
paretic, or any other nervous symptoms develop, a careful in- 
vestigation should never be omitted, since a direct relation will 
in a certain number of cases be clearly evidenced, and removal 
of the cause will speedily cure the manifestation. The fact that 
even circumcision does not relieve the symptoms is undoubtedly 
true in many instances, and I have never maintained that pre- 
putial adhesion and narrowing was anything more than one of 
several factors which should be carefully scrutinized. I have 
only urged that its influence should not be overlooked, and, 
when so simple an operation as stripping the prepuce from the 
glans by the thumbs, or possibly by the use of a probe, is all- 
sufficient, there can certainly be no argument against removing 
this one factor. My opinion in regard to the feasibility of 



* "Philadelphia Medical Times," June 30, 1883. 



July 11, 1885.1 



MISCELLANY. 



55 



drawing back the prepuce in young children, even when the 
opening seems scarcely pin-hole in diameter, has been greatly 
strengthened, and circumcision is only necessary when the sim- 
pler method described fails to secure a prepuce freely movable 
over a normal glans. Dilatation even is but rarely required, a 
few minutes of continuous pressure soon revealing the mucous 
layer, adherent perhaps just about the meatus, which, when 
loosened, permits the head to pass through the opening, and 
the corona is freed with the thumbs. Should temporary para- 
phimosis occur, two probes or a hair-pin slipped beneath the 
constriction will easily permit replacement. 

(7b be concluded.) 



The American Medical Association and the International Medical 
Congress.—" The meeting of the American Medical Association, held at 
New Orleans during the past month," says the " Kansas City Medical 
Record," in its June issue, " did not prove to be as much of a success 
as was anticipated. We presume this may be accounted for on the 
ground of the location, the country in the vicinity of New Orleans be- 
ing sparsely occupied by physicians, and the territory well occupied by 
the profession being at a great distance, rendering it a tedious journey 
at a great sacrifice of time. Hence the attendance from our large East- 
ern and Northern cities was very light. 

"There were about five hundred physicians present, mostly from the 
South and West. The papers read, both in general^ session and sec- 
tions, were quite practical as a rule, and full of interest, and received a 
pretty thorough discussion. 

" Many of the leading representative men who usually attend the 
meetings being absent detracted from the general interest, and pre- 
vented the meeting reaching the average standard of American Medical 
Association meetings. . . . 

" The second day of the meeting was ushered in by a somewhat ver- 
bose discussion regarding the action of the committee relative to the 
International Medical Congress. From our best information regarding 
the gentlemen who were instrumental in initiating this uncalled-for 
wind-storm, we fancy the trouble originated from disappointment 
They are sore-heads of the ' rule or ruin ' type. Some of these men 
have for years endeavored to supply the wind-power for the American 
Medical Association meetings. 

" The International Medical Congress requires a more reliable power 
— a steadier power ; hence these dress-parade sort of fellows were, of 
necessity to the welfare of the Congress, relegated to the rear. 

" In order to conceal the true character of the charges, they hid 
behind the new-code prejudices charging that new-code men were put 
on the committees. However objectionable the new-code men may be, 
we hope they are governed by purer principles than men whom we 
know to be ostensibly sticklers for old-code theories, but are practically 
no-code practitioners, except such as will give them personal aggran- 
dizement. 

" We have carefully looked over the ' rules and preliminary organi- 
zation,' and can see no reason to find fault with the action of the com- 
mittee. We feel entirely satisfied that they have acted in the best in- 
terest of the American profession in general. Nearly all the States, the 
District of Columbia, and Canada have been represented by the appoint- 
ment of prominent and distinguished physicians on the committees and 
sections. New York, having the largest number of widely known men, 
is justly entitled to a larger number of representatives, and therefore 
has 68 appointments ; Pennsylvania, which might be expected to come 
next, has 48; Massachusetts, 32; Illinois, 18; Ohio, 15; District of 
Columbia, 18; Missouri, 8. A few States are left out, which can be 
the only tangible objection to the appointments. 

" It must not be forgotten that the States so largely represented are 
those in which most of the medical teachers and authors reside, without 



whom, be they new- or old-code men, the American profession could 
not be represented in its best light, which, above everything of a tech- 
nical nature, should be sought after." 

The Use of Cocaine in Nervous Affections. — At the recent meeting 
of the American Neurological Association, Dr. J. K. Bauduy, of St. 
Louis, read a paper in which he recounted his experience with the use 
of cocaine in the treatment of certain forms of psychical disturbance. 
We expect to publish Dr. Bauduy's paper shortly. In the mean time, 
we would call attention to a letter which has been shown us, written by 
Dr. L. Bremer, of St. Louis, from which we make the following ex- 
tracts : "Dr. Bauduy, of this "city, has been using the cocaine in cases 
of melancholia with the happiest results. During a recent visit at St. 
Vincent's Hospital I was, by the kindness of the doctor, afforded an 
opportunity of witnessing the rapid and wonderful effect which the 
hypodermic injection of one grain of the drug produced in the affection 
named. W. EL, aged seventeen, who was under my treatment before 
his admission to the hospital, for hebephrenia, and whose mental state 
I am thoroughly familiar with, was, on our visit, found in a condition 
of great depression. Although he knew me well, he refused to speak 
to or recognize me. The expression of his face was that of utter de- 
jection, despair, and disgust. All efforts to elicit an answer to my 
questions failed ; he remained wrapped up in a sullen silence. The 
injection of one grain of cocaine changed the scene as by magic. Four 
minutes after the introduction of the drug the patient began to talk ; 
the spell was broken, and he conversed freely and intelligently on the 
nature of his trouble. The almost mathematical precision of the effect 
of the remedy could only be compared to that of morphine in certain 
nervous affections. 

" The second case in which the cocaine was tried in my presence, 
and yielded a like brilliant resifTt, was that of a young man suffering 
from a severe form of melancholia combined with a refusal to take 
nourishment. Five minutes after the administration of the drug he 
became quiet and partook readily of the nourishment offered to him. 
This patient would never eat except when under the influence of the 
drug; it was employed for the first time when he was approaching 
inanition, to avert which the feeding-tube was thought of as a last 
resort. ... To my knowledge, Dr. Bauduy has been the first to try co- 
caine in melancholia." 

Dr. Bauduy seems to have been the first also to suggest the use of 
cocaine for the morning sickness of pregnancy. An interesting account 
of Dr. Schenck's experience with the remedy for that distressing con- 
dition will be found in the report of the proceedings of the St. Louis 
Medico-Chirurgical Society, published in the " St. Louis Courier of Medi- 
cine " for May, where it is expressly stated that the cocaine was used at 
the suggestion of Dr. Bauduy. 

The New York Polyclinic. — Dr. M. Allen Starr has been elected 
professor of diseases of the mind and nervous system in the New York 
Polyclinic. 

The " International Journal of the Medical Sciences." — Beginning 
with the issue for January, 1886, according to the "British Medical 
Journal," this will be the title of the " Americal Journal of the Medical 
Sciences," Dr. Hays continuing as the American editor, and Mr. Malcolm 
Morris being the European editor. 

The Health of the State of New York. — It appears, by the " Month- 
ly Bulletin " issued by the State Board of Health for the month of May, 
that the total reported mortality was 6,542, the percentage of infant 
mortality being 32'23. In each thousand deaths there were 154 70 
from zymotic diseases, including 26 - 83 from measles, 18'10 from scarlet 
fever, and 48"91 from croup and diphtheria. 

The Health of Michigan. — From a statement issued by the secre- 
tary of the State Board of Health, Dr. Henry B. Baker, we find that, 
during the month of June, diphtheria was reported from forty-one 
places, scarlet fever from twenty-seven, measles from sixteen, and 
small-pox from two. 

The Missouri State Board of Health was lately reorganized by the 
choice of Mr. William Gentry as president, Dr. George lloman as secre- 
tary, and Mr. J. B. Prather as treasurer. 



56 



MISCELLANY. 



[N. Y. Med. Jons. 



THERAPEUTICAL NOTES. 

A New Species of Agaric. — Grossi, says the " Gazzetta degli ospi- 
tali " (quoting from " Kif. med."), has recently made a study of a gigan- 
tic species of agaric, the Polyporus senex, found on the coast of Chile, 
the absorbent properties of which are remarkable. Although it is in- 
soluble in ether, in chloroform, and in alcohol, it effervesces in the pres- 
ence of bicarbonate of sodium, becomes smooth and unctuous, breaks 
up, and dissolves. Grossi has made use of it as a styptic, and regards 
it as a specific in cases of haemorrhage from wounded arteries that are 
too small to tie, and too large to be controlled by other styptics ; also 
in the hsemorrhagic diathesis. He has employed it for night-sweats 
also, after the following formula : 

Polyporus xenex 3 \ grains ; 

Bicarbonate of sodium 15 " 

Distilled water 3 ounces ; 

Gum arabic 75 grains. 

A tablespoonful to be taken at night. 

A New Basis for Ointments and Suppositories. — In the same publi- 
cations it is stated that the seeds of the //<y/<" sphndidn and the Hopea 
aspera, if not those of some other species, furnish a fatty matter, known 
in the Islands of Sunda as myniak-tangkawank or myniaksangkawank, 
which is used in the industrial arts, and seems likely to answer in the 
preparation of ointments and suppositories. 

The Treatment of Goitre with Iodoform Injections. — Thiroux 
(These de Paris, 1884; "Rev. med.") records several cases in which 
interstitial injections of iodoform were followed by considerable im- 
provement and even cure. At the military hospital at Bordeaux these 
injections have been found to give so jnuch pain, due probably to the 
ether in which the iodoform was dissolved, that their use has been 
given tip. 

Parthenine in the Treatment of Facial Neuralgia. — Tovar has 
experimented with this alkaloid in cases of facial neuralgia (" Gazz. 
med. Ital.-Lombard."). Giving a tenth of a grain every hour for four 
hours, and then decreasing the size and frequency of the dose, he cured 
rather a severe case in a week. Parthenine is obtained from Parthe- 
mum hysteropJwrus, an herb growing in Jamaica, where it is much 
used for cutaneous affections. 

Anisic Acid as an Antipyretic. — This substance (Ibid.), obtained 
by the oxidation of oil of anise, takes the form of colorless prismatic 
crystals soluble in alcohol and in ether. It has antiseptic properties, 
also an antipyretic action analogous to that of salicylic acid. It should 
be used with caution, as large doses injected into the veins of various 
animals have caused epileptoid convulsions. 

A Ready Method of stopping Hiccough. — A Brazilian physician, 
Dr. Ramos ("Bull. gen. de therap."), states that refrigeration of the 
lobe of the ear will stop hiccough, whatever its cause may be. Very 
slight refrigeration will answer — the application of cold water or even 
of saliva being sufficient. 

The Fruit of the Calabash Tree as a Purgative. — According to 
Peckolt (" Nouveaux remedes"), both the pulp and the expressed juice 
of this South American tree, the Cresccntia cujete [Linnaeus], have long 
been used as laxatives in Brazil. The alcoholic extract, in doses of a 
grain and a half, is a laxative, and acts as a drastic in doses of seven 
or eight grains. The fresh pulp is also employed as an application in 
cases of erysipelas. It is boiled with water until it forms a black 
paste, then vinegar is added, and the mixture is boiled again. It is 
applied spread on linen. 

Hydrofluorate of Quinine. — According to Weddel (Ibid.), this salt 
is soluble in water and in alcohol. He has used it in the treatment of 
hepatic engorgements of malarial origin, in which, he thinks, fluorine 
and the fluorides have a beneficial action. He has observed the same 
in rickets and other nutritive diseases of the bones. 

Paraldehyde as a Hypnotic. — At a recent meeting of the North of 
Ireland Branch of the British Medical Association (" Brit. Med. Jour."), 
Mr. Hodgson, of Brighton, gave his experience with this drug in cases of 
insomnia unaccompanied by pain, especially in mania, hypochondriasis, 
delirium tremens, and [so the account states] migraine. As compared 
with chloral, it had the advantage of not being a cardiac depressant. 



For gout, both acute and chronic, he strongly recommended it, finding 
that sleep was obtained, while the solid constituents of the urine were 
increased rather than diminished. When either the throat or the stom- 
ach was inflamed, it was unsuitable, owing to its pungency, and this 
quality rendered free dilution always necessary. As an anodyne, he 
considered it weak, but he had found that it heightened the effect of 
morphine. 

Anagyrine. — This is the name given to an alkaloid extracted by 
Hardy and Gallois from Anayyrix ftetida and A. indica. At a recent 
meeting of the Societe de biologic (" Gaz. hebdom. de med. et de chir."), 
M. Hardy reported that small doses had been found to act as a tonic, 
but that large doses, given to small animals, produced death by arrest- 
ing the respiration. 

Deelina Oil in the Treatment of Skin Diseases. — Dr. John Rob- 
erts, of Chester, England (" Practitioner"), gives brief notes of a num- 
ber of cases of skin disease, chiefly of an eczeruatous character, in 
which he has used " oleum deelinae " as a topical application. He con- 
siders it superior to all other fatty substances for the purpose. He 
never uses it during the acute stage. Before it is applied the parts are 
bathed with warm bran-water or oatmeal-water, and then carefully and 
gently dried. All that is said of the nature of the oil is that it is " an- 
other member of the hydro-carbon family," and that it is " manufac- 
tured on the banks of the Dee, by the Dee Oil Company, by a process 
of refining," etc. We find nothing in the article to indicate whether it 
is a fish-oil, a petroleum product, or of vegetable origin. It is said that 
it is clean and inodorous, does not become rancid, and leaves little or 
no greasiness after its application. 

Iodoform in the Treatment of Syphilis. — Dr. H. Macnaughton 
clones (Ibid.) states his experience of the value of iodoform adminis- 
tered internally in certain cases of syphilis in which the iodides appeared 
to have little effect. He does not generally give it in larger doses than 
a grain or a grain and a half, three times a day. He continues its use, 
unless it is contra-indicated by some sense of fullness in the head or 
headache. Especially when used in conjunction with the external ap- 
plication of iodide of starch, he has seen it prove of striking benefit 
in cases, of ecthymatous ulceration. Like iodide of potassium, it is 
not borne in any quantity by some persons, while there are others who 
can safely persevere with it for a considerable time. 

An Anaesthetic Mixture of Dimethylacetal and Chloroform, two 
volumes of the former to one of the latter, has been used at the Strass- 
burg surgical clinic in a hundred and fifty cases. Fischer (" Dtsch. 
Ztschr. f. Chir." ; " CtrlbL f. Chir.") says that its advantages are that 
psychical excitement and muscular agitation do not occur, but the pa- 
tients pass gradually into a quiet sleep ; that vomiting, and efforts at 
vomiting, are not observed during the anaesthesia, and occurred after 
consciousness was regained in only four cases (those of very anaemic 
patients who had been allowed to drink a good deal after the opera- 
tion)- and that the disappearance of the anaesthesia is very rapid, and 
leaves the patient feeling comfortable, without any headache. The 
mixture is recommended : 1. When gastric catarrh and vomiting are 
especially to be avoided. 2. For laparotomy. 3. In cases of heart 
disease. 4. In nephritis. 5. In diseases of the central nervous sys- 
tem, particularly infantile paralysis and epilepsy. 6. In cases in 
which untoward symptoms come on during chloroform anaesthesia 
and the operation can be completed only with the aid of an anaes- 
thetic. The drawbacks are the slowness with which anaesthesia is 
induced in robust, muscular individuals, and the high price of dimethyl- 
acetal. 

The External Use of Chloral for Night - Sweats. — Nicolai 
("Wratsch"; "St. Petersb. med. Woch.") remarks that the usual 
remedies for night-sweats have the disadvantage that the system soon 
becomes accustomed to their action, and that, consequently, the dose 
has to be so increased that unpleasant collateral effects are produced. 
The external use of chloral, he says, is free from this objection. He 
uses a mixture of two drachms of chloral and two beerglassfuls of 
equal parts of brandy and water. With this mixture the patient is 
bathed at bedtime. If this is not enough, a clean night-shirt is put on 
which has been soaked in the solution and then dried. This treatment 
is said to be particularly successful with children when the trouble is 
not due to phthisis. 



THE NEW YORK MEDICAL JOURNAL, July 18, 1885. 



LECTUKES ON 
ELECTRICITY IN MEDICINE, 

DELIVERED AT THE MEDICAL DEPARTMENT OF THE UNI- 
VERSITY OF VERMONT, BURLINGTON, 

By AMBROSE L. RANNEY, M. D., New York. 

(Continued from page 32.) 
THE CARE OF A BATTERY. 

The best battery is liable to get out of order. It is an 
easy matter, as a rule, to correct the trouble if the construc- 
tion of the apparatus is thoroughly understood. The follow- 
ing hints may aid the reader in obtaining a satisfactory cur- 
rent with a minimum expense : 

1. Keep yoxir battery clean and bright in all its parts. 
Close the case when the battery is not in use, and thus keep 
out dust, grease, and moisture. Emery-paper is useful to 
keep the metal connections free from rust. Remember that 
dirt, grease, or rust will often arrest the action of any bat- 
tery. 

2. When the battery fails to act properly, examine the 
cells first and see if the fluid requires renewal. The " red- 
acid fluid " is easily made by adding one part of commercial 
sulphuric acid to ten parts of cold water ; when cooled, one 
part of finely pulverized bichromate of potassium should be 
added and mixed well. This is the fluid commonly em- 
ployed in portable batteries with cells of the Grenet pat- 
tern. 

3. If the fluid is found to be fresh, and if the zinc and 
carbon elements are in good order and the zinc well amal- 
gamated, examine carefully all the screws and other connec- 
tions attached to the elements and see if they have become 
oxidized. Sometimes they become rusted or so covered 
with accumulated dirt as to render the passage of the cur- 
rent impossible. Occasionally the carbons may be discon- 
nected and baked in an oven to render a Grenet cell more 
active. Soaking the elements (in situ) in hot water which 
does not reach the connections will generally suffice to 
cleanse them. 

4. If the cell has become polarized when in action (by 
bubbles of hydrogen which accumulate upon the carbon and 
of oxygen upon the zinc element), lifting the zinc out of the 
fluid and replacing it immediately will suffice to overcome 
this trouble if the cells are of the Grenet pattern. These 
bubbles of hydrogen and oxygen set up a counter-current in 
the cell which will weaken and may even neutralize the 
original current. 

5. Examine the interrupter, the buttons of the current- 
selector, and the commutator for rust or dirt, and clean each 
thoroughly when the trouble appears not to be due to the 
elements or their immediate connections. 

6. If a drip-cup is furnished with a faradaic or galvanic 
battery, be careful to place the zinc element in it when the 
battery is not in use. 

7. In portable galvanic batteries, be sure to place the 
rubber-covered diaphragm over the cells before closing the 



case and to screw it down tightly. This prevents the fumes 
rising and oxidizing the connections of the elements when 
not in use. This does not apply to a red-acid battery when 
not being transported. 

8. Be sure that the rheophores are perfect before they are 
used upon a patient. The wire used in their manufacture 
is liable to become broken or oxidized by use. This is 
especially true of the flexible, cotton-covered cords generally 
furnished with batteries. The electrodes may be tested by 
employing a galvanometer, if an imperfection is suspected 
and can not be found. 

9. The wires that run from the cups to the buttons of 
the current-selector or the commutator may be seen on the 
bottom side of the key-board of a battery. They can be 
examined for imperfections when the other parts of the ap- 
paratus appear to be perfect. 

1 0. Do not short-circuit a battery. By this we mean, do 
not allow a battery to run down, or, more technically, " polar- 
ize," by the poles being brought into contact without an 
interposed body (such as animal tissue) for any length of 
time. For example, galvanic cells which have a low internal 
resistance (as a Grenet cell) become polarized in a few hours 
when the poles are connected by a short wire which affords 
little if any resistance to the current. 

11. Keep your electrodes clean. It is well to cover them 
with fresh canton-flannel for every patient. This is an act 
of precaution which will impress people with your regard 
for their feelings and for their safety from contact with in- 
fectious matter. Sponges are too expensive to be renewed 
so often. Absorbent cotton may often be placed between 
the electrode and its covering with advantage. 

Part II. 

The Principles of Electro-Diagnosis.* 

The various electric tests that are employed as aids in 
the diagnosis of nervous affections are too complex to be 
fully described and explained without entering somewhat 
into the domain of physics and physiology. Erbf has 
lately written an excellent work upon the subject, and 
most of the later treatises upon physiology will afford you 
general information respecting the reactions of healthy mus- 
cle to the faradaic and galvanic currents. The few practical 
hints which are given here are offered with an apology for 
their incompleteness, although it is hoped that they will 
assist you in your studies in this field. 

Having first moistened the electrodes and connected 
them with the battery in action, it is customary to hold 
them both in one hand (close together, but not in contact), 
and apply them to the ball of the thumb of the opposite 
hand or the cheek to see if the current is passing properly. 
If the current to be employed is a very weak one, touch the 
electrodes to the tip of the tongue before it is used upon 
the patient. 

Next, sponge the part of the patient's body to be tested 
with a tveak solution of table-salt in warm water, in order to 



* Portions of (his lecture have already been published, 
f "Handbook of Electro-Therapeutics," New York, 1883. 



58 



RANNEY: LECTURES ON 



ELECTRICITY IN MEDICINE. [N. Y. Med. Jouk., 



render the skin a good conductor of the electric currents. 
If the wire-brush is to be used, this step is omitted. 

The "polar method " is the one commonly used. Apply 
one electrode of large size, either over the breast-bone of 
the patient (at about its center) or over the back of the 
neck. The breast-bone is the preferable point on account 
of the absence of muscles in the median line.* The other 
electrode (of small size) is placed over some special nerve- 
trunk or the muscle to be tested ; in case muscle is to be 
tested, the electrode is placed usually at the point where 
the motor nerve enters its substance — the so-called " motor- 
point" of the muscle. In this way the action of the two 
poles can be readily distinguished. 

In my work, "The Applied Anatomy of the Nervous 
System," I have reproduced von Ziemssen's cuts, illustrat- 
ing the situation of the motor-points of the various mus- 
cles. In case the interrupted or faradaic current is to be 
employed, the " polar method " need not be strictly adhered 
to, as it is decidedly more painful than when the electrodes 
are less widely separated. 

Use both the continuous or galvanic current and the 
interrupted or faradaic current in testing muscular reactions. 
The former is of the greatest value in diagnosis. 

In studying the muscular reactions to the different cur- 
rents employed, remember (1) that the negative pole is 
called the cathode (C),f and the positive pole the anode 
(A) ; (2) that muscular contractions occur both when the 
current is altered in strength and when the circuit is closed 
or opened ; (3) that the faradaic current produces an appa- 
rently continuous muscular contraction, because its inter- 
ruptions are so very rapid ; (4) that very weak currents do 
not produce contractions ; (5) that alterations in the strength 
of the current cause proportionate variations in the contrac 
tions ; (6) that the contractions are short, sharp, and sud- 
den in health ; (7) that the effects of applying the electrode 
over the substance of the muscle and over its motor-point 
are identical in health, but not in some diseased conditions ; 

(8) that the galvanic current will not usually produce mus- 
cular contractions while it is constant, but only when its 
strength is modified or when the circuit is closed or broken; 

(9) that the direction of the current can be changed, with- 
out altering the position of the electrodes, by a simple appa- 
ratus that changes the cathode into the anode, and vice versa 
(the commutator). 

The current passes always from the anode to the cathode. 
Hence, when the positive pole is placed on the breast or 
neck, and the other on the muscle to be tested, we have a 
descending current. An ascending current exists if the anode 
is on the same distant or neutral point. 

An " automatic interrupter " on an " interrupting elec- 
trode " is necessary in employing the galvanic current in 
testing muscular reactions. 

* This is known as the " indifferent point," when polar effects are 
being studied at the other electrode. 

\ German authors employ different symbols from those given. 
These are as follows : C. C. C. = Ka S. Z., C. 0. C. = Ka 0. Z., A. C. 
C. = An S. Z., A. 0. C. = An 0. Z. The symbols Ka = cathode, An 
= anode, S = closure (ScMiesmng), 0 = opening (Oeffnung), Z = con- 
traction (Zuckung). 



The descending current, when closed and again broken, 
can thus give us : 

1. The cathodal closure contraction : 

C. C. C. or Ka S. Z. of the Germans. 

2. The cathodal opening contraction : 

C. O. C. or Ka O. Z. of the Germans. 
The ascending current, when closed and again broken, 
can give us : 

1. The anodal closure contraction : 

A. C. C. or An S. Z. of the Germans. 

2. The anodal opening contraction : 

A. O. C. or An 0. Z. of the Germans. 

These four forms of contraction require currents of 
different strengths to produce them. They are, therefore, 
induced by gradually increasing the number of cells em- 
ployed. The following order is the one commonly observed 
in healthy muscle : 

1 C. C. C. = Ka S. Z. 

2 A. C. C. = An S. Z. 

3 A. O. C. = An O. Z. 

4 C. O. C. = Ka O. Z. 

It will be observed that the cathodal contractions appear 
first and last in health, while the anodal contractions follow 
each other ; also, that the closure contractions precede the 
opening contractions of both the cathode and anode. When 
a nerve-trunk is stimulated by electric currents the formula 
of the normal muscular contractions is altered. This will 
be spoken of hereafter. 

As the strength of the current is gradually increased, 
the contractions which have successively appeared become 
intensified proportionately (as is shown below), and new 
reactions are added : 

First stage {moderate current), C. C. C. 

Second stage [stronger current), C C C and A. C. C. 

Third stage [still stronger current), C." C." C." and A.' 
C C and A. O. C. 

Fourth stage [very strong current), CV" C" C" and A." 
C." C." and A.' O.' C and C. O. C. 

C" C" C" is called " cathodal tetanus" because the 
contraction is very violent. Sometimes the anodal con- 
tractions both occur with the same intensity of current, 
thus merging the second and third stages into one. 
Again, A. 0. C. may in some cases appear before A. 
C. C. 

Disease of the nerve-centers or of the nerves themselves 
may cause modifications of the normal formula of muscular 
contractions. This constitutes the key-note to the value of 
electric currents in diagnosis. Mechanical devices may be 
employed to trace the muscular contractions, as the sphyg- 
mograph does the pulse. (Fig. 32.) 

If the destructive process is within the brain or spinal 
cord, and situated above the " trophic centers " of the nerves 
supplying the paralyzed muscles, the electrical reactions of 
the paralyzed muscles will be normal in respect to the se- 
quence and character of the muscular contractions. Some- 
times, however, a mttch stronger current (galvanic or fara- 
daic) is required to produce them than over the healthy 



July 18, 1885.] 



RAN NET: LECTURES ON ELECTRICITY IN MEDICINE. 



59 




■• 


L 


is A 




i 




" ' ' " • ; ./> 

; ; ' J j; 


Ka 


An ■ 


Ka.. , An 


Ka. 




Ka .An ' 


; Ka. An 















. j 






7 ■ 




' ■ V 




. Art ; .:. ••• 




An 




.-1)1 



muscles. This fact is due to atrophic changes in the mus- | contractions, irrespective of the strength of the current em- 
cles. It may be of decided value in diagnosis. ployed. 

When disease processes in the brain or spinal cord cause I Finally, in unilateral paralysis the electrical reactions of 

the muscles of the paralyzed side should 
be contrasted with those of homologous 
muscles of the unaffected side. When 
both sides are impaired, the standard of 
comparison should be that of a healthy 
subject of about the same size, weight, 
and muscular development. 

Now let us suppose that we wish to 
test the reaction of some special nerve — 
the musculo-spiral, for example. \\ e 
place the positive pole (An) of a gal- 
vanic battery over the breast-bone with a 
large flat electrode attached, and the 
negative pole (Ka) over the nerve (where 
it winds around the humerus below the 
deltoid muscle) with an "interrupting" 
small electrode attached to the nega- 
tive rheophore. We then put into cir- 
cuit a few cells at a time and press the 
button of the interrupting electrode at 
intervals till we get a contraction of mus- 
cles. When the current is sufficiently 
strong to excite the nerve-trunk, contrac- 
tion of the extensor muscles of the forearm becomes ap- 
parent (the cathodal closure contraction^. Thus we ascer- 
tain the number of cells required to produce C. C. C. 
(Ka S. Z. of the Germans). Now add a few more cells, 
and reverse the poles by means of the commutator. When 
the circuit is broken, by releasing the button of the inter- 
rupting electrode, we get the anodal opening contraction 
(A. 0. C, or An O. Z.), and, with a few more cells, the 
anodal closure contraction (A. C. C, or An S. Z.). Again 
reverse the current, and add a few more cells. Now, on 
pressing the button of the interrupting electrode, we get a 
very intense cathodal closure contraction (C"\ C-". C'"., 
or Ka S. 21".), and, on releasing it, the cathodal opening 
contraction (C. O. C, or Ka O. Z.) is developed, thus com- 
pleting the chain of polar nerve-reactions. 

You should bear in mind that the polar nerve-reactions 
differ in their normal sequence from those of the muscles 
when the electrode is placed over the "motor point " of the 



Fig. 32.— Curves op Closure Contractions in Direct (Unipolar) Stimulation op the Mus. 
cles in the distribution of the peroneal nerve in the leg (erb). ka = c. c. c. ; an 
= A. C. C. 1, Curve of health, thirty-three elements ; C. C. C. is greater than A. C. C. ; 2, case 
of chronic anterior poliomyelitis, showing reaction of degeneration with thirty-three elements ; 
3, same case, with forty elements. In 2 and 3, the excess of A. C. C. over C. C. C. is apparent ; 
3, in the slow character of the contractions is very marked. 

destruction of the trophic centers of the nerves that supply 
the paralyzed muscles, or when the cerebrospinal nerves 
themselves are seriously injured, we encounter what Erb has 
described as the "reaction of degeneration." This will 
require some explanation. 

1. Every nerve degenerates when separated from its tro- 
phic center ; hence, the electric excitability of the nerve, 
both to the faradaic and galvanic currents, gradually dimin- 
ishes and ceases entirely at the end of about two weeks. 

2. The faradaic current ceases to cause muscular con- 
tractions when applied directly over the substance of the 
muscle. This is explained by the fact that the so-called 
" nerve-plates " within the substance of the muscle are de- 
generated, and currents of momentary duration fail to affect 
the muscular fibers. 

3. The muscular contractions produced by the galvanic 
current are diminished for about ten days. Subsequently 
the excitability of the muscles to slowly interrupted galvanic 
currents becomes increased, so that very weak currents may mU scle tested, 
excite contractions. This may disappear in five or six 
months. 

4. The polar reactions become altered in their sequence. 
The anode contractions appear before those of the cathode, 
as shown below : 

1 A. C. C. instead of C. C. C. as in health. 

2 C. C. C. " A. C. C. " " 

3 C. 0. C. " A. 0. C. " " 

4 A. O. C. " C. O. C. " " 

5. The character of the muscular contractions becomes 
altered. In health, they are sharp, short, and sudden. 
When degeneration occurs, they arc slow to appear ; they 
are prolonged and continue even during the passage of the 
current ; and, finally, they assume the character of " tetanic " 



NORMAL NERVE-REACTION. 

C. C. C.>A. O. C>A. C. C>C. O. C. 

NORMAL MUSCLE -RE ACTION. 

C. C.'OA. C. C>A. O. OC. O. C. 

The final contraction (C. O. C.) of each of these series 
is seldom seen, because the current required to produce 
it is too painful to be endured. Fewer cells are required 
to cause muscular formula; than those of a nerve-trunk. 

In recording the results of an electrical examination of 
nerve-trunks and muscles it is best to arrange the record- 
page so that the two sides of the body may be easily con- 
trasted. The number of galvanic cells employed or the 
number of milliamperes of current (as shown by a galvanome- 
ter) should also be specified, and the faradaic reaction of 



60 



RANNEY: LECTURES ON ELECTRICITY IN MEDICINE. [N. Y. Med. Jocb., 



homologous nerves or muscle should be stated for the pur- 
pose of comparison and for clinical deduction. We may 
follow with advantage some such plan as the following: 

Name Date, .... Age, .... 

History of Case. See page .... of Case-Book. 
Faradaic Tests. 





Right side. 


Left side. 


Extent of sec" 
ondary coil 
• employed. 
(In centime- 
tres.) 


Nerve tested. 


Muscle-reactions .... 








Muscle tested. 





Galvanic Tests. 





Right 
side. 


Contraction 
produced. 


Left side. 


Nerve or 
muscle 
tested. 


Nerve-reactions. . 1 


Cells. 


C. C. C. 
A. 0. C. 
A. C. C. 
C. 0. C. 


Cells or milliainperes 


1 

j nerve. 


Muscle-reactions . -f 




C. C. C. 
A. C. C. 
A. 0. C. 
C. 0. c. 




\ muscle. 



Slips of this character may be printed and kept on hand. 
They can be pasted into the case-book of the physician 
when filled out. The tests made at different dates can thus 
be compared with each other and the progress of each case 
determined. 




Fig. 3.3.— The Author's Spring Electrode.— D, the binding-post for attach- 
ing the rheophore which connects it with the battery, or with the diagnostic 
key-board when that instrument is employed. The motor point of the elec- 
trode is represented as enveloped in chamois-skin. It must be thoroughly 
dampened in salt-and-water before it is applied to the nerve or muscle to be 
tested The other end of the electrode is designed to prevent slipping of 
the instrument after its proper adjustment. 

For the purpose of demonstrating the special action of 
individual muscles and nerves before classes of students, as 
well as the study of muscle- and nerve-reactions in disease, 
I have devised small electrodes which may be made station- 
ary upon any desired part of the head, limbs, or trunk, by 
means of straps, strips of adhesive-plaster, or insulated 
springs. By means of these I have been enabled to make 
many points clear to a large audience which would be ex- 
tremely difficult to show by any other method. Further- 
more, it is often desirable to refer from time to time during 
an examination of. a patient to the effects of currents of 
known intensity upon certain nerves and muscles for the 
sake of accurate comparison, etc. Small electrodes of the 
type described may be accurately placed upon a patient and 
allowed to remain upon the spot selected during the entire 
examination. To each of these a separate rheophore may 
be attached and, by a simple device of my own, each may be 



controlled by touching a key upon a board, without move- 
ment of the operator. I can thus observe simultaneously 
the reactions of corresponding muscles or nerves upon the 




Fig. 34. — The Author's Diagnostic Key-board.— A, the rheophore which 
connects it with one of the binding-posts of a galvanic battery ; B, rheo- 
phores connecting its binding-posts with spring electrodes previously placed 
upon the body of the patient so as to influence the nerves or muscles to be 
tested ; C, buttons and springs which make a circuit to the body of the 
patient when the knob on the spring is pressed downward so as to impinge 
upon the button. The number of rheophores which may be employed 
depends upon the necessities of the case ; the cut shows an instrument 
capable of six. 

two sides, those of the leg and arm of the same side, and 
any other comparisons which may be required in diagnosis. 
The " motor-points " of the body are not always exactly 
where charts depict them ; hence it is sometimes necessary 
to hunt for them within a radius of an inch or two of the 
normal point. When they are found with exactness, a small 
electrode may be fastened over the spot (with moistened 
absorbent cotton beneath it) and allowed to remain station- 
ary during the entire sitting. Whenever it becomes neces- 
sary to refer to the reactions of that point, it can be called 
into action by touching the key connected with it by its 
individual rheophore. The cuts introduced show the ar- 
rangement of my device for this purpose. I have given a 
more complete description of the advantages of this method 
over others previously employed, in the " New York Medical 
Journal" of May 9, 1885. 

Now, from such a table of record it is apparent that the 
faradaic current should first be employed upon the patient 
(the poles of the secondary coil being used). The extent 
of the overlap of this coil (in centimetres) necessary to 
produce muscular contractions when the nerve- and muscle- 
reactions are being separately tested should be recorded. 
In case no muscular contractions ensue, the extent of the 
overlap which produces an unbearably painful current should 
be ascertained and noted. This may be compared with that 
necessary to produce contractions upon the healthy side. 
The " polar method " should be employed in the tests thus 
made and recorded. 

The next step in the examination consists in changing 
the rheophores to the binding-posts of a galvanic battery. 
We can now ascertain the number of cells or of milliam- 
peres (which is preferable) required to produce the different 
varieties of contractions (enumerated in the table designed 
for record) of muscles in homologous regions of the right 
and left sides. Each nerve which is impaired should be 
tested first ; and the muscles supplied by it should be tested 
afterward. The strength of the current employed should 
be ascertained by throwing a galvanometer into the circuit 



Jnly 18, 1885.J 



RANNEY: LECTURES ON ELECTRICITY IN MEDICINE. 



61 



(when extreme accuracy is desired) ; by so doing, a compari- 
son of the nerve- and muscle-reactions of the two sides can 
be based upon conditions which are exactly alike. 




Fig. 35.— The Author's Diagnostic Key-board as applied in Actual Use. The spring electrodes 
are represented in the cut (for the purpose of illustration) as applied to the facial, ulnar, and musculo- 
spiraf nerves of each side. If he chooses, the operator can have his case-book on a stand at his right, 
for recording his observations as they are made. 



AVhen we have completed the steps indicated by the 
chart prepared for the assistance of the beginner we are in 
possession of certain facts which may be of great practical 
value as regards both diagnosis and prognosis : 

1. Suppose a case of localized paralysis is examined, and 
the faradaic and galvanic reactions of both a nerve and its 
muscles are normal and exactly alike on the two sides. We 
have reason then to believe that the exciting cause is either 
hysteria, a lesion of a higher spinal segment than that from 
which the nerve arises, or a lesion within the brain, pro- 
vided the possibility of deception on the part of the patient 
respecting his paralytic condition can be excluded. 

2. If the nerve-reactions of the affected side to both 
currents are exaggerated (i. e., if the contractions occur in 
their proper sequence, but under a weaker current than in 
health), the probability of an existing central lesion is height- 
ened, although hysteria may possibly still exist as the ex- 
citing cause of the paralysis. 

3. If the faradaic current applied through the nerve fails 
to produce contractions of the affected muscles as readily as 
upon the healthy side (i. e., if a stronger current is de- 
manded to call any one of the paralyzed muscles into action 
indirectly through the nerve which supplies it), then we know 
that the nerve filaments within the spinal cord or the trunk 
of the nerve itself are affected by a lesion which has impaired 
but not entirely destroyed their usefulness. 

4. "If no current from a faradaic machine (which can be 
endured by the patient) causes muscular contractions, we 
know positively that the motor cells of the anterior horns of 
that spinal .segment which controls the paralyzed muscles 



are destroyed, or that the nerve itself has been severed from 
its connection with the spinal cord. 

5. When the muscle-reactions to the faradaic current 
have been tested, the previous deduc- 
tions (based on the nerve-reactions) 
still hold good. The electrode should, 
however, be placed over the " motor 
point " of each muscle thus tested. 

6. If the formula obtained by the 
galvanic current are normal, all ques- 
tions regarding the existence of de- 
generative changes in the nerve- or the 
muscle-plates can be excluded. When 
the normal order is altered, degenera- 
tive changes in the nerve- or the 
motor-cells of the spinal cord are 
present. 

7. The history of a case in which 
motility is impaired is never complete 
without a record of an electrical ex- 
amination of the nerve- and muscle- 
reactions to both the faradaic and gal- 
vanic current. When doubt exists 
respecting the existence of a cerebral 
lesion or hysteria, the facts obtained 
by other methods of examination (fully . 
described by me in the " Medical Rec- 
ord," March, April, and June, 1884) 
will clear up all doubts. 

8. Patients afflicted with paralysis from a cerebral lesion 
generally exhibit normal electro-nerve and electro-muscular 
reactions in the paralyzed parts. In some instances the 
reactions may even be exaggerated. 

9. Hysterical patients afflicted with paralysis may ex- 
hibit either normal or exaggerated electro-muscular reac- 
tions to faradism or galvanism. The sensitiveness of the 
muscles to faradism is generally decreased ; in some cases 
it may be totally wanting (Duchenne). 

10. In rheumatic 2 Mra ly s * s the electro-muscular con- 
tractility is, as a rule, markedly increased ; this may be 
shown by a comparison of the reactions of the two sides of 
the body. In exceptional cases this is not found to be so, 
as I have seen the reactions follow only the strongest cur- 
rents. 

11. In peripheral paralysis the faradaic and galvanic 
reactions are altered after ten days have elapsed. The mus- 
cular contractility to the faradaic current is lost earl} to a 
greater or less extent ; and the formula of degenerative 
changes is developed later by the employment of the gal- 
vanic current. 

12. A decreased musculo-exeitability to the faradaic 
current in the musculo-spiral nerve and the extensor mus- 
cles of the forearm on both sides — the flexors being normal 
and the lower extremities being unaffected — tells us of the 
approach of lead-poisoning before the actual symptoms are 
well marked. 

13. In progressive muscular atrophy a response to the 
faradaic current can be obtained as long as any filters in tlie 
muscle tested remain free from fatty metamorphosis. 



RANNEY: LECTURES ON ELECTRICITY IN MEDICINE. 



[N. Y. Meu. JorR., 



14. No alterations in the electro-contractility of muscles 
is observed in any of the diseases confined to the posterior 
part of the spinal cord. 

DETECTION OF FEIGNED DISEASES. 

In addition to the uses of electricity for the purpose of 
determining the presence or absence of nerve- and muscle- 
degeneration, and the discrimination between cerebral and 
spinal paralysis and the various types of peripheral palsies, 
some other useful purposes in diagnosis have been published 
from time to time. 

The Detection of Death. — It is stated that muscular con- 
tractions produced by the faradaic current can not be main- 
tained over four hours in a dead subject. 

Malingerers are not uncommon among the applicants 
for charitable aid, and they are occasionally encountered 
among the higher walks of life. Epilepsy and paralysis are 
the most common diseases which are feigned. 

Feigned epilepsy can be distinguished by the application 
of a strong faradaic current to the forehead or tibia by 
means of a wire-brush. The intense pain so produced will 
not be appreciated by a true epileptic, but will bring the fit 
to a sudden close, if assumed in order to create sympathy 
or aid. 

Feigned motor paralysis is usually exhibited in some of 
the various forms of peripheral paralysis. Few malingerers 
know enough to simulate hemiplegia or paraplegia without 
detection. If two weeks have elapsed since the attack, the 
presence of normal electrical reactions of nerve and muscle 
in the affected limb is strong ground for suspicion, pro- 
vided a history of some cerebral lesion or of hysteria can 
not be elicited. There are various other tests which a 
skilled anatomist can employ in each case that will help to 
clear up all doubts upon this subject. 

Feigned anesthesia may be told by the use of the fara- 
daic current with the wire-brush attached to the negative 
rheophore. The opposed limbs will quickly show how 
much actual anaesthesia exists. 

Detection of Bullets or Buried Metal. — An ingen, 
ious application of electricity to surgery has been made 
which has utility in diagnosis. 

The so-called " electric probe " consists of two wires 
which are perfectly insulated from each other by rubber or 
ivory. These wires terminate in metal tips which project 
slightly beyond the insulating medium, and at the other 
end of the wires a galvanic cell and an electro-magnet act- 
ing upon a bell are attached. When the probe is pushed 
into the tract made by a metallic missile, and the tips are 
brought into contact with it, the circuit is completed and 
the bell rings. The animal tissues are not sufficiently good 
conductors of electricity to form a circuit; hence the bell 
will not ring until the metal is touched by the tips of the 
probe. 

Electro-diagnosis of Aural Diseases. — We owe to 
Brenner, of St. Petersburg, the first suggestions of this use 
for electric currents in diagnosis. From a somewhat limited 
experience in its use, I am led to believe that its utility can 
not longer be called into question. Brenner's formula 
seems, furthermore, to be in accord with all that has been 



proved in respect to nerve-trunks in health, in all parts of 
the body. The formula is simply that of the galvanic reac- 
tions of the auditory nerve in health. 

1. In place of the C. C. C. observed in muscle, we get, 
when a galvanic current is sent through the auditory nerve, a 
ringing noise when the cathodal closure occurs. (C. C. S.) 

2. The cathodal opening produces no effect. 

3. The anodal opening produces a ringing noise when a 
current of high intensity is employed. 

4. After the cathodal closure {cathodal duration — C. D.), 
the ringing noise produced at the closure gradually dimin- 
ishes. . • 

The formula which is indicative of health when a pole 
is connected with each ear may be expressed in symbols, as 
follows : 

Right Ear (Anode). Left Ear (Cathode). 

C. (closure) .... S. (loud) 

O. (opening)... . S. (weak) 

D. (duration) S. > 

Now, it is maintained by Brenner that any deviation 
from the normal reactions of the auditory nerve (shown in 
the preceding formula) indicates disease of the acoustic 
mechanism. The variations produced by the different dis- 
eased conditions encountered can not be given here from 
want of space. 

In applying galvanic currents to the ear, it is best to 
place a medium-sized electrode over the entire tragus, or to 
fill the external auditory canal of the ear to be tested with 
tepid water containing a little salt, and then to introduce an 
electrode of metal inclosed in an aural speculum of hard 
rubber into the ear until the metal touches the water. If 
each ear is to be tested separately, the other electrode should 
be placed at an indifferent point, preferably the mastoid 
region of the same side or the middle of the sternum. 

Regarding this test, it is well to state that repeated sit- 
tings are often necessary. The patient has to become accus- 
tomed to the disagreeable effects of the current. It is de- 
sirable that you begin with very weak currents and increase 
the strength very gradually. As the reaction of cathodal 
closure (C. C.) is the most important," it can be intensified 
by previously allowing cathodal duration (C. D.) to act, or 
by rapidly following C. C. by A. O. 

Examination of the Eve, Nose, and Mouth by Elec- 
tricity. — Special effects are produced upon the organs of 
sight, smell, and taste by electric currents. Sparks or vivid 
Hashes of light follow electric stimulation of the eye; and 
subjective odors and tastes are also produced when the ol- 
factory and gustatory nerves are excited by this agent. The 
"polar method" of examination is employed when any of 
the special senses are thus tested. I would caution each of 
you against employing too strong currents about any of the 
organs of special sense. The examination of the optic, ol- 
factory, and gustatory nerves recpiires experience and should 
not be attempted by novices. 

When examining the reactions of the eye, the small elec- 
trode is placed upon the closed eyelid, temple, or forehead. 
The large electrode is placed upon the back of the neck. 
The room should be darkened and the patient should keep 
both eyes closed. 



July 18, 1885.] 

When iesting the sense of taste, the poles should be in 
contact with the cheeks, and the sensations of taste experi- 
enced upon both sides by the patient should be ascertained. 
A fine electrode can also be placed upon the tongue, the 
pharynx, or the inside of the cheek, in case localized polar 
reactions are to be determined. A double electrode, with 
two metal tips which are not in contact, may be employed 
for this purpose (Neumann). 

Electrical Examination of the Sensibility of the 
Skin. — The electrode devised by Erb is to my mind the 
best for this purpose. It consists of four hundred varnished 
wires in a tube of hard rubber. The ends of these wires 
make a perfectly smooth surface. This electrode is con- 
nected with the secondary coil of a faradaic machine and is 
then pressed upon the area of the body to be tested — the 
other pole being at the sternum. The minimum of the 
overlap of the secondary coil which can be felt and the 
maximum which can be endured are both recorded. Ho- 
mologous parts of each side should be compared with each 
other. 




Fig. 36.— Erb's Electrode tor the Examination op Farado-cutaneous 
Sensibility, a, a hard-rubber tube ; b, the free surface of the electrode. 

Regarding this test Erb wisely remarks : " The skin, 
regarded as a sensory organ, can not be tested with irritants 
other than those adequate to it — viz., touch, pressure, vari- 
ous temperatures, and the higher grades of those irritants 
which produce pain. It may be disputed whether electric- 
ity should be included among these ' adequate ' irritants of 
the skin. The electric sensation is a specific, distinct qual- 
ity of tegumentary sensibility, whose careful examination, 
however, is of value in many morbid conditions." 



flPrigural Communications. 

ANTISEPTIC INHALATIONS* 
By BEVERLEY ROBINSON, M. D. 

In a paper read before the Practitioners' Society of 
New York last winter, " On the Utility of Intra-pulmonary 
Injections in the Treatment of Pulmonary Phthisis," I said 

* Read before the American Climatological Association, May 27, 
1885. 



63 

that I intended, at an early date to bring before my medi- 
cal colleagues the subject of antiseptic inhalations. In the 
brief paper I now offer for your consideration I shall do 
this, but I shall not limit myself solely to the consideration 
of the advantages of these inhalations in pulmonary phthisis. 
Already I have made use of them in several affections of 
the respiratory tract — both acute and chronic. Although 
the cases treated by me in this manner are not yet numer- 
ous enough to afford a solid basis for final conclusions, they 
are at least sufficient to point distinctly to an extensive and 
beneficial trial of this method in a large class of respiratory 
diseases. The method is not new, it is old ; but it is also a 
case of revival, with more precise data to establish its spe- 
cial indications and employment. To any one who has 
made frequent use of steam vapor inhalations, and hot or 
cold atomized fluids or sprays, the great advantages of the 
plan which forms the theme of this study, in the treatment 
of the affections referred to, is too real to be lightly con- 
sidered or entirely ignored. 

In its favor may be cited the following propositions : 

1. The apparatus required costs but a trifle, and may be 
used, therefore, even by the poorest classes. 

2. Medication thus apjjlied may be employed under cir- 
cumstances where the use of hot or cold sprays is imprac- 
ticable. 

3. There are no risks of future colds attendant upon its 
employment. 

4. The relief afforded by dry vapor inhalations is, in my 
experience, frequently greater than that given by the other 
methods of inhalation. 

5. This medication is well adapted to all forms of irrita- 
tive disease of the respiratory passages. 

I know of only one serious objection which can be prop- 
erly urged against its very general adoption, and it is the 
statement that the vapors of volatile antiseptic substances, 
when they are employed in the ordinary oro-nasal inhaler, 
do not penetrate far enough to reach the pulmonary cells, 
and, therefore, can not possibly modify this structure in 
any sensible degree. 

Upon experimental grounds, Arthur Hill Hassall (" Lan- 
cet," May 5, 1883) has endeavored to show that the agents 
most frequently employed hitherto — such as carbolic acid, 
creasote, thymol, etc. — are but feebly volatile at ordinary 
temperatures. He has also been unable, after prolonged 
inhalation, to recover any notable quantity of these sub- 
stances in the sputa or secretions from the air-tract. In 
fact, he has not even remarked that the sputa, soon after 
they were expectorated, were penetrated with their odor. 
Indeed, after continuous inhalations of one or two hours' 
duration, he has succeeded in obtaining, by Chandelon'a 
process, from the sponge or cotton in the inhaler, very 
nearly the whole quantity of the agent employed. A 
sufficient answer to these objections, it seems to me, may 
be found in the fact that the patients themselves, when 
questioned, after they have used the inhalations dur- 
ing a few days or weeks, as to their utility, almost in- 
variably reply that their subjective symptoms have been 
notably relieved by them. Not only do they make this 
statement, but they add, further, that their sputa have di- 



ROBWSON: ANTISEr I IG INHALATIONS. 



64 



ROBINSON: ANTISEPTIC INHALATIONS. 



[N. Y. Med. Joce., 



minished in quantity, and at times have notably changed in 
appearance. Moreover, while I am willing to admit that 
dry vapors do not enter the lungs so deeply as we might 
presume, or indeed as, theoretically, we might desire, yet 
they certainly do go further than the sprays for which they 
have been substituted. I am of the opinion, also, that the 
small loss of substance which has not been recovered, and 
which possibly does penetrate the pulmonary air-cells, is 
sufficient to modify notably, after several days or weeks of 
more or less continuous inhalation, the inspired air in such 
a manner that it is made comparatively aseptic, and thus we 
have an influence for good that we can properly estimate 
only by the evident effects produced. In regard to the 
areas of cough in the bronchial tubes, as in the lung itself, 
I believe something may be learned by reference, first, to 
my own experiments with intra-pulmonary injections, and, 
second, to the well-known facts recorded by Hack and J. N. 
Mackenzie in their investigations upon the nasal passages. 
In my experiments I was led to believe that pulmonary 
cough was largely due to irritation produced at the apices. 
And surely this conviction need not be a matter of surprise, 
since we all know that the sensitive area for cough in an- 
other organ (the nose), physiologically allied to the lungs, 
is not general, but limited almost to the posterior extremi- 
ties of the turbinated bodies. 

Again, is it not true that, in many cases where there is 
notable effusion into the air-cells at the pulmonary bases, as 
in oedema following chronic Bright's disease or organic 
heart disorders, there is usually little or no cough ? When- 
ever, on the contrary, as in commencing bronchitis or 
phthisical infiltration, there are obvious morbid changes at 
the apices, what more obstinate and constant symptom can 
be observed than the ceaseless racking cough ? Finally, I 
have on more than one occasion, I am confident, punctured 
the lung deeply in searching for pleuritic fluid, either pos- 
teriorly or in the axillary line, as was evident by the blood 
and air withdrawn into the cylinder of the hypodermic 
syringe, or into the pump of the aspirator, and cough has 
not followed invariably. This fact is, however, also true in 
regard to punctures at the pulmonary apices; but here the 
intra-pulmonary alterations have been very different from 
what existed at the bases at the time punctures were there 
made. In the former cases the lungs were already infil- 
trated with tubercles which blocked up the bronchi and 
surrounded their periphery ; in the latter cases the bron- 
chial tubes were inflamed or compressed, it is true, but 
were not, as a rule, completely impervious to air. Mucus 
and serum, blood-streaked or not, they usually contained, 
no doubt, but even then their condition was such as to 
render them a priori more sensitive than they should be 
under wholly normal circumstances. 

I will now place before you some of the results of my 
trials with dry vapor inhalations up to the present time, and 
if, by their analysis, I can prove the utility of this method 
clinically, I shall hope to stimulate further inquiry, and per- 
suade many of you to give it the opportunity which, I be- 
lieve, it merits. It is understood, I assume, that I do not 
claim any originality for the treatment of my cases. These 
dry inhalations were reintroduced to the profession, as you 



are all aware, some years ago by Dr. W. Roberts, of Man- 
chester, England, and since that time have been more or 
less extensively employed by H. Curschmann, of Hamburg, 
and by several other able practitioners at home and abroad. 
Among these I would cite particularly William Pepper, in 
the "Transactions of the American Medical Association" 
for 1880; J. H. Tyndale, New York "Medical Record," 
March 18, 1882 ; J. Barney Yeo, in his " Lectures on Con- 
sumption," London, 1882; S. S. Cohen, in Philadelphia 
" Medical News," October 11, 1 884 ; J. Ward Cousins, " Lan- 
cet," July 19, 1884; and A. Hill Hassall, " Lancet," August 
16, 1884, and "Inhalation Treatment," London, 1885. . 

The following summary shows the number and nature of 
the cases of which I have preserved notes, but does not 
represent one half the number of patients for whom I have 
ordered oro-nasal inhalers. I regret to add that, even in those 
cases of which I possess a record, several were not studied 
with much care, and, consequently, my remembrance of the 
results obtained is very imperfect. A sufficient number 
remain, fortunately, in which I have watched carefully the 
effects of dry inhalations, and about whose condition, before 
and after their use, I can speak with more assurance. 

My tabular statement includes twenty-two cases of 
phthisis pulmonalis, catarrhal or tubercular, at its first stage, 
or when already there were evident and characteristic signs 
of tissue infiltration. 

In four of these cases there were marked local pleuritic 
adhesions. In the remaining cases no statement is made 
other than the fact that pulmonary consolidation at the 
apex or apices was present. 

Nineteen cases of pulmonary phthisis, catarrhal or tu- 
bercular, at its second stage, were treated partly by means 
of oro-nasal inhalers. Of these nineteen cases, in eleven the 
softening was limited to one apex ; in two cases both apices 
were thus affected, while in the other cases no reference is 
made to the limitations of the disease. There were six 
cases of fibroid- phthisis treated by inhalers; three cases of 
laryngeal phthisis, in one of which there was commencing 
carious ulceration of the vocal cords. There were two 
cases of acute laryngitis, seven cases of subacute laryngitis, 
three cases of chronic laryngitis, two cases of subacute 
bronchitis, three cases of chronic bronchitis, five cases of 
chronic nasal catarrh, four of which were of the hypertro- 
phic form, the remaining one being distinctly atrophic ca- 
tarrh, with which were connected a condition of pharyn- 
gitis sicca and a notable degree of foetid odor of the breath 
(ozaena). I also treated in this manner one case of chronic 
pharyngitis, two cases of localized pleuritis, and one of 
paralysis of the tensors of the vocal cords — the total mak- 
ing seventy-six cases which form the basis of the remarks I 
shall make before you to-day. 

First, in regard to pulmonary phthisis at its first stage. 
Of this disease I have the records of twenty-two ca>es in 
which I used dry vapors. The inhalations consisted of, 1, 
creasote and alcohol equal parts; 2, creasote one part, ol. 
pini sylvestris two parts, and compound tincture of benzoin 
eight parts ; 3, compound tincture of benzoin ; 4, fir-wood 
oil ; 5, fir-wood oil sixteen parts, creasote one part ; 6, fir- 
wood oil six parts, chloroform two parts; 7, creasote one 



July 18, 1885.] GRAY: TWO VALUABLE AIDS 



TO ELECTRO-THERAPEUTICS. 



65 



part, fir-wood oil sixteen parts ; 8, compound tincture of 
benzoin and fir-wood oil, equal parts ; 9, spirits of turpen- 
tine ; 10, volatile oil of eucalyptus; 11, carbolic acid and 
tincture of iodine, of each one part, compound tincture of 
benzoin eight parts; 12, fir-wood oil one part, succus conii 
and compound tincture of benzoin, of each two parts, car- 
bonate of magnesium, q. s., water eight parts ; 13, pine-nee- 
dle oil; 14, terebene four parts, spirits of chloroform one 
part. 

It will be remarked that I varied considerably the 
nature and composition of the substances employed for in- 
halations — and this is specially notable if the limited num- 
ber of my cases be considered. I made these trials ad- 
visedly, as I was very desirous to find out not only if* vapor 
inhalations were useful, but, indeed, if certain combinations 
were more effective than others under similar conditions. 

The results of my observations would seem to show that 
the most generally useful inhalation in the beginning of pul- 
monary phthisis is creasote and alcohol, equal parts. Crea- 
sote by itself is a little too irritant, and is not so readily ma- 
nipulated. Whether or not the mixture of alcohol increases 
its volatility I am not positive, although I believe it does, 
regard being paid to the statements of patients. The 
amount of inhaling fluid employed with best results varied 
from ten to twenty drops. It was also renewed most ad- 
vantageously two or three times in twenty-four hours. The 
inhalations were employed at first about ten minutes every 
two, three, or four hours. After a week or two they could 
be continued, without unpleasant effects, one half or one 
hour at a time, and repeated three or four times in twenty- 
four hours. If a larger quantity of the inhaling fluid was 
used at first on the sponge of the inhaler, or if at first the 
time for each inhalation was extended beyond fifteen min- 
utes, the patient suffered from irritation of the throat and 
increased painful cough on several occasions. The form of 
inhaler employed by me was usually one not dissimilar in 
outward conformation to that employed by Burney Yeo, of 
London, and S. S. Cohen, of Philadelphia. It may be of 
interest in this connection to give a short account of the 
different oro-nasal inhalers in use at the present time. Some 
of these are shaped so as to cover the mouth alone, some 
are adapted simply to inhalation through the nose, and 
some encircle both nose and mouth. They are made of 
metal, hard rubber, or celluloid, and are usually constructed 
from a single sheet of the material employed, their particu- 
lar shape being made to suit the requirements of the major- 
ity of individuals. In Blake's and Tyndale's inhalers, which 
cover both nose and mouth, there is a circular valvular 
opening on either side, about one third of an inch in diame- 
ter, which closes by means of a soft rubber flap that rises or 
falls with each inspiration or expiration, and is intended to 
promote the facility of expiration and to avoid the passage 
of respired air through the sponge charged with the inhal- 
ing fluid. In llassall's oro-nasal globe inhaler similar val- 
vular openings on the sides have been provided, and this 
inhaler has the additional advantage, as stated by its in- 
ventor, of supplying a larger amount of medicated vapor to 
the patient for purposes of inhalation. This result is effect- 
ed by reason of the considerable capacity of the globe itself 



for containing bits of lint moistened with a suitable amount 
of inhaling fluid, and owing to the wider orifice of commu- 
nication between the globe and the oro-nasal piece, or shield, 
which allows plenty of medicated vapor to pass through and 
be inhaled with each inspiration. When an inhaler is fitted 
to the nose alone, it is better, as a rule, for the patient to ex- 
pire through the mouth than through the nose, as in this 
way a more complete circuit of the nasal passages by the 
vapor is accomplished than if expiration took place through 
the nose. None of the inhalers described, although some- 
what more elaborate and expensive, seem to me so useful as 
the cheap and simple one here shown. This one, as you 
perceive, is made of a thin sheet of perforated zinc ; it is ex- 
tremely light, and may be worn, therefore, a long time with- 
out causing the fatigue to the patient which the other inhal- 
ers often do. It also permits the air to pass freely in and 
out, and thus obviates almost entirely the sensation of oppres- 
sion and stifling, which is apt to make the prolonged use of 
the other oro-nasal inhalers almost impossible. 

One of the objections urged against the efficacy^ of most 
oro-nasal inhalers, is the fact that too small a supply of vapor 
is given off from the small bit of sponge, cotton, or tow 
which comes with them to be of any benefit to the patient. 
In the globe inhaler Dr. Hassall has remedied this supposed 
defect. For my part, I have not usually found it a defect, 
and I have rarely found the slightest difficulty in supplying 
my patients, by means of the perforated zinc inhaler, with all 
the medicated vapor they could comfortably endure. In- 
deed, I have observed several times, as other observers have 
done before me, that the quantity of antiseptic liquid added 
to the sponge of the inhaler must be limited to a few drops 
(10 to 20) if the inhaler is worn more than a short time. 
If a relatively large quantity of antiseptic fluid be added to 
the sponge, the vapors proceeding from it are too concen- 
trated and shortly become very irritating to the air-passages, 
and the inhaler must be abandoned. Instead of doing good, 
therefore, by adopting the latter manner of medicating the 
sponge of the inhaler, we actually do harm and render a 
very serviceable agent a decidedly objectionable one. I am 
therefore not of the opinion of Dr. Hassall as regards this 
point in inhalation— viz., that with the ordinary forms of 
oro-nasal inhalers we do not volatilize a sufficient quantity 
of antiseptic fluid to be of service as an inhalant ; and even 
when we volatilize enough fluid not enough antiseptic va- 
por is inhaled to modify the air-cells to any notable de- 
gree. 

(To be concluded.) 

TWO VALUABLE AIDS TO 
ELECTKO-THEE A PEUTICS. 

By LANDON CARTER GRAY, M. D., 

PROFESSOR OF NERVOUS AND MENTAL DISEASE, NEW YORK POLYCLINIC : AT- 
TENDING PHYSICIAN TO ST. MART'S HOSPITAL : ATTENDING PHYSICIAN TO 
THE HOSPITAL FOR NERVOUS AND MENTAL DISEASE. 

One of the greatest of the difficulties that have been 
encountered by the electro-therapeutist has been the lack of 
a suitable galvanic battery. Of good faradaic machines 
there has been no dearth, especially since the invention of 
the cheap and portable apparatus made by Gaiffe, of Paris. 



66 



GRAY: TWO VALUABLE AIDS TO ELECTRO-THERAPEUTICS. [N. Y. Med. Jooh., 



But the galvanic batteries for general use have been un- 
pleasantly heavy, and the Grenet cell, or some modification 
of it, which has been mostly employed in them, is a con- 
stant source of annoyance from the necessity of frequent 
renewal of the plates and still more frequent renewal of 
the fluid. I have therefore, for years, been on the search 
for some combination of elements that would be portable 
and durable in a far greater degree than the Grenet cell. 
My attention was called to the fact that Gaiffe was con- 
structing a battery with the chloride-of-silver elements that 
seemed to answer the requirements ; but the importation 
was costly and troublesome, and the cells had to be sent to 
Paris for renewal. Dr. De Watteville, of London, very 
kindly put me in communication with Mr. Schoth, an instru- 
ment-maker of London, who had been experimenting with 
the same cells at Dr. De Watteville's instance ; but Mr. 
Schoth had not yet constructed a battery with them. Finally 
I ascertained that Mr. John A. Barrett, a New York elec- 
trician, was making a battery with these cells. This instru- 
ment I have now been using daily for some five months, and 
I am prepared to say that its general employment will 
mark a new era in galvano-therapy. The cut (Fig. 1) gives 




Fig. i. 



some idea of the size of the battery, but a better one can 
be obtained from the statement that an instrument contain- 
ing thirty-two cells will only measure ten inches in length 
and weigh only nine pounds, while a fifty-cell one will 
measure twelve and a half inches and weigh twelve pounds. 
As will be perceived by electro-therapeutists, such a bat- 
tery is by all odds the lightest that has yet been con- 
structed. As to its durability, it is calculated that each 
cell will stand two hours' steady work daily for nine months, 
or a proportionate length of time otherwise arranged, be- 
fore the elements will need renewal. Practically, therefore, 
such a cell will last the general practitioner a year or 
more, and the cost of renewal will be about eight dollars. 

The details of construction are as follows: The cells con- 
sist of cylindrical bottles of black rubber. These bottles arc 



fitted with screw stoppers or caps of the same material, which 
are fastened permanently to the underside of a black rubber 
plate. The elements, zinc and chloride of silver, are fast- 
ened to silver wires which pass in pairs up through suitable 
perforations in the caps and plate, and are attached on the 











• 1 


















Fig. 2. 

upper surface of the plate to fixed studs or pins so arranged 
that the zinc and silver poles of the successive cells are con- 
nected together through the entire battery. The bottles 




Fig. 3. 



are partly filled with solution and are screwed from under- 
neath to the caps, each bottle inclosing a pair of elements. 
The bottom of each bottle is provided with a slot, so that by 
a key the bottles may be screwed tightly to their caps. By 
this means the entire set of bottles is rigidly attached in 
an upright position to the plate, and at the same time any 
bottle may be removed independently of the others and its 
pair of elements examined, or removed and replaced, without 
inconvenience. Besides this, all the connections, being on 
the upper side of the plate, are easy of access and out of the 
reach of corrosion. The battery, thus prepared, is placed in a 
box, and a top-plate, perforated to fit the connecting studs, is 
laid over it. This top-plate is numbered for convenience in 
making connections. It is easily removable, and the whole 
battery may be readily lifted out of the box. In the lid of the 
box is placed a commutator or pole-changer, to which are at- 
tached short flexible cords terminating in hollow plugs. By 
these plugs any number of cells may be selected from any 
part of the battery. The pole-changer is also provided with 
two binding-posts, to which the conducting cords are to be 
attached. In the lid of the box are also springs for holding 
a pair of electrodes and handles. The strength of the 
battery is very nearly equal — within — to the same 
number of Daniell or blue-vitriol cells, and is maintained 
undiminished until the material is exhausted. 

The instrument which, as I have already said, I have 
had in daily use for some five months, and which has many 
days been jolted about in my carriage over rough city streets 



July 18, 1885.] 



CUETISS: IMMUNITY IN DISEASE. 



67 



for five or six hours at a time, has maintained its current 
unimpaired in quantity or quality. 

Another great need of the electro-therapeutist has been 
some means of measuring the quantity of electricity — some- 
thing that will answer to the balance of the apothecary. It 
is quite usual to hear those using electricity speak of giving 
the patient so many cells for such a contingency and so 
many cells for another, which is just about as sensible as 
it would be to advise a man to wear so many coats in the 
Arctic zone and so many in the Antarctic, without specify- 
ing the texture that shall make up each individual coat. 
The sine and tangent galvanometers, which are used by 
those employing electricity in the arts, are too cumbrous 
and expensive for medical needs. Gaiffe, Bottcher, Stohrer, 
Edelmann, and Hirschmann have each devised an absolute 
galvanometer. Of these, the ones constructed by Gaiffe 
and Hirschmann have been the best. Dr. De Watteville 
enthusiastically indorses the former, while others allege that 
it is faulty. Hirschmann's instrument has been well de- 
scribed by Dr. B. Sachs.* I have had no experience with 
it, but it appears to me to be complicated, and Dr. Sachs, 
after a year's use of it, states that " it does not bear trans- 
portation well, and the return of the needle to the zero 
point is slightly impeded by the action of friction." It 
seems, however, barring these disadvantages, to be a good 
instrument. The cost seems to me to be the main drawback 
to it. There has lately been constructed in this city an ab- 
solute galvanometer which is superior, in my opinion, to any 
other for the purposes of the electro-therapeutist. A cut is 




Fig. 4. 



herewith appended. The unit of measurement is the mini- 
am pere — a unit which has lately come into use for medical 
purposes. It was first suggested in 1878 by Dr. De Watte- 
ville, and was adopted by the special committee of the In- 
ternational Congress of Electricians. It represents the cur- 
rent given by three Daniell's cells through the average 
resistance of the human body, and medical currents range 
in strength from one to fifty of these units. 

The scale is graduated from one to fifty of these new 
units. The working parts of the meter are inclosed in a 
case about four inches square at the base and six inches 
high, having a glass face, showing the pointer and scale. 
The pointer is attached to the movable magnetic needle, 
which is a steel disc suspended within a surrounding coil 

* "Jour, of Nerv. and Mont. Dis.," vol. xii, No. 1, Jan., 1885. 



of wire on two knife-edges, so as to oscillate freely in a 
vertical plane. The movements of the magnet are indicated 
by the pointer on the scale. The magnet is counterbalanced 
and held in equilibrium, so that the pointer rests at zero, by 
means of a small weight fixed to it below the center of 
gravity. These are so arranged that the position of the 
instrument relatively to the earth's magnetic poles is of no 
account. The magnet, being so poised on frictionless knife- 
edges, would be subject to prolonged and troublesome oscil- 
lations ; but a dampening device is provided which consists 
of a vane or fan of thin mica, extended upward from the 
magnet in the back part of the case by means of a light, 
rigid stem of aluminium. This vane moves broadside against 
the confined air and brings the needle quickly to rest in 
any position, without, in the smallest degree, interfering with 
its sensitiveness. A locking arrangement also forms a part 
of the instrument, by which the magnet may be lifted from 
its bearings and fixed in an immovable position. By this 
means the knife-edges and movable parts are protected 
from damage during transportation and when not in use. 
A leveling screw is placed on one side below, so that the 
instrument may readily be adjusted to a proper position. 

In use, the meter is placed in the circuit with the body 
of the patient, so that all the current which flows through 
the body flows also through the meter. In this situation 
the pointer of the instrument gives a deflection which meas- 
ures in absolute units the current actually passing and 
doing work in the body. 

The luxury of such an instrument can hardly be over- 
estimated by any one making daily applications of elec- 
tricity and desiring to work rapidly and precisely. For 
example, a patient comes to you to-day, and you find that 
you can employ twelve cells of your battery with no un- 
pleasant effect. To-morrow he comes to you again, and, to 
your surprise, you find that you need twenty-four cells to 
obtain the same effect. The third day he comes still 
again, and squirms with pain when you turn on more than 
six cells. Your milliampere-meter solves the mystery. It 
tells you that all the time your patient has borne about 
ten or fifteen milliamperes of electricity, and that the daily 
differences have been due to variations in the conductivity 
of the skin, moisture in your sponges, heat of the moisture, 
etc. 

IMMUNITY IN DISEASE. 

By ROMAINE J. CURTISS, M. D., Jouet, Iix., 

PROFESSOR OP HYGIENE IN THE COLLEGE OF PHYSICIANS AND SURGEONS, 
CHICAGO. 

(Concluded from page £2.) 

One of the more important correlatives of the immunity 
from disease given by natural selection is the history of (he 
great epidemics of plague, black-death, typhus, etc. These 
epidemics, during the dark ages, killed millions of people, 
and were prevalent more or less continually. These dis- 
eases were not conquered by sanitation. An epidemic now- 
adays makes just as violent a warfare in Europe as epidem- 
ics ever did, provided there is no acquired physical resistance 
of tissue-cells to the poison of the germ. But the old epi- 
demics lost their power and declined, and finally became 



68 



CUBTISS: IMMUNITY IN DISEASE. 



[N. Y. Meu. Jolr., 



practically extinct. Efforts have been made to attribute 
this extinction to sanitation. The London fire lias been 
given the credit of conquering the sweating-sickness, and 
the suppression of typhus and scurvy as epidemics has been 
ascribed to the efforts of John Howard and Captain Cook ; 
but if cleanliness, or alleged cleanliness, or prevention of 
putrefaction, has cleaned out leprosy, black-death, jail-fever, 
etc., why are not cholera, typhoid, diphtheria, scarlatina, 
and other zymotics also subdued by the same alleged clean- 
liness ? I think the only method of explaining the cessation 
of the old epidemics is the method of natural selection. 
When the epidemics prevailed, the germs, by combat with 
tissue-cells, caused a variation in the cells. The persons 
who acquired and maintained this variation transmitted it 
to their children. In time there was built up a community 
of people who had the power of resisting the germs of 
these epidemics, and the epidemics died out. 

I think we may apply this action of natural selection in 
the community, as it is seen to subdue epidemics, to the 
person, in order to explain the self-limitation of disease, 
both limitation in duration of time and the limitation of 
disease of different kinds to .corresponding organs or tis- 
sues. Syphilis appears not to be limited to any definite 
time, nor to any particular tissue or organ. Probably, 
next to syphilis, tuberculosis meets with less resistance 
among cells, and has less evidence of being self-limited in 
time. There is evidence, however, that both of these dis- 
eases are subject to the general law of limitation in both 
time and successful antagonism from certain tissues. Syphi- 
lis is certainly less violent than formerly. Modern authors 
speak freely on this subject. This is not because treatment 
has improved, for the treatment is the same now as when 
syphilis was almost certain death. It is because the whole 
of Christendom is syphilized, and natural selection is bring- 
ing the races of men out of the bonds of this disease. The 
various tissues of the body are acquiring a power of resist- 
ance to the syphilis germ and its poison, and transmitting 
this power of resistance by heredity. If one tissue after 
another of the body acquires a resistance to the poison, it is 
a sequitur that in time the tissue which is the last to acquire 
the resistance will show the only signs and symptoms of the 
disease. Syphilis will then be more limited in point of dif- 
fusion throughout the body, and must necessarily be of 
shorter duration. It will then present, in this respect, the 
characters of those diseases which are limited to certain 
tissues, and to a more definite period of time, notably 
typhoid, scarlatina, measles, small-pox, etc. 

But another feature of the question is that the develop- 
ment of organisms is a resultant of actions and interactions 
between them, so far as they are related to each other. When 
the struggle for life is limited to a struggle between organ- 
isms, the variation is not limited to one of the combatants 
alone. Each gets a share of the variation. If the animal 
attacked by a micro-organism acquires a variation giving 
it greater resistance, it is likely that the attacking organism 
by this means acquires greater virulence. The "survival" 
in such a case bears direct relation to the organism which 
has the greater resources. That the human species exists 
to-day is proof enough that humanity at large is able to 



survive in spite of the enemies which cause disease ; and 
that the species survives by reason of natural selection 
would appear to be clear enough. The defense appears to 
be a variation of the cells in their power to resist a poison, 
while the variation in the disease organism is an increase in 
its virulence. The variation of the species of micro-organ- 
isms by natural selection is a verified fact, and upon it 
depend all the benefits derived from inoculation. If the 
pathogenic organism of hydrophobia is bred in the bodies 
of certain lower animals, it loses virulence. There can be 
no method of accounting for this fact except that the tissue- 
cells of the animal have less resistance than those of the 
other animals which have given the organism its greater 
virulence. The Bacillus anthracis is modified in the same 
manner by artificial cultivation. On the other hand, reli- 
able experimenters have determined that B. subtilis (hay 
bacillus) can, by cultivation and inoculation, be changed to 
B. anthracis. This variation of the species produces cor- 
responding varieties in disease, and is the fact that underlies 
the immunity to disease which is brought about by vaccina- 
tion or inoculation. There are several methods of produc- 
ing these varieties, such as cultivation, dilution, attenuation, 
washing, etc. If natural selection can not explain these 
various methods, I do not know what will or can. The 
organism, varied from the type of its species in this way, as 
a general thing, is unable to cause disease by entrance into 
the body in the usual way, but depends upon accident. 
The accident must include an injury to the tissues or celk 
such as obtains in inoculation. When a wound is made 
the cells are destroyed. Most organisms are proof against 
septic bacteria unless there is a wound. Human beings have 
outgrown, or rather out-developed, septic bacteria, unless 
their invasion is preceded by an accident which causes a 
wound. AYounded cells and tissues have lost their power 
of physical resistance. 

Another feature of inoculation is that the artificial 
method of gaining a foothold inside the resistance of the 
organism subject to disease, by means of inoculation, has 
the effect of shortening the period of incubation. This is 
true of inoculations of all varieties of pathogenic organisms. 
It is, therefore, an inference and a verified truth that vac- 
cination may prevent small-pox, even after exposure to the 
latter. To deny the proposition is to deny that the period 
of incubation is shorter in vaccination than in small-pox, 
and the denial is also, by antithesis, an assertion that kine- 
pox will not prevent small-pox. 

Dr. Eccles's inference from his own data, as well as from 
the facts here expressed, that the treatment of small-pox by 
vaccination, or vaccination after exposure to small-pox, is 
like treating strychnine poisoning by another dose of 
strychnine, is one of the most stupendous instances of 
logical' non sequitur to be found in medical literature. In 
order to draw a like inference from different propositions, 
the terms of the propositions must have some relations of 
likeness. In Dr. Eccles's inference and statements there is 
no shadow of likeness. He must first prove that the in- 
cubation of small-pox from exposure is equal in time to 
that of vaccination, and also that vaccination will not pre- 
vent small-pox. If he had said that infecting the blood of 



July 18, 1885.] 



GURTISS: IMMUNITY IN DISEASE. 



69 



a small-pox patient with more small-pox poison was like 
treating strychnine poisoning with more strychnine, the 
terms of his proposition would have had more analogy- 
Testimony shows that vaccination is good medical treat- 
ment for small-pox, and, while the fact remains that kine- 
ppx can prevent small-pox, the inference will be unavoidable 
that the germs of each, in relation to the host and the dis- 
ease, are antagonistic physiologically — as much so as atro- 
pine and morphine. Their antagonism may depend upon 
the priority of their invasion of tissues. Their difference is 
the degree of .virulence of each, but in relation to the tissues 
either is the antagonist of the other. 

But Dr. Eccles's hypothesis, or absurdity, can be used 
to good purpose. Suppose that on a future given day a 
person is condemned to swallow a given poisonous dose of 
strychnine, or arsenic, or morphine, and wishes to prepare 
for it. In such a case the best method for the person will 
be to accustom himself to the use of the poison. If Socrates 
had known the relations of natural selection to the action of 
poisons, he might have drank his hemlock with no less 
grandeur and have saved his life. Dr. Eccles simply in- 
verts the terms of natural selection in relation to poisons. 
His proposition looks formidable and strange. It reminds 
one of the man who tried to frighten a bull by standing on 
his head with his feet in the air. The man's appearance 
was unique, if not frightful, but was no protection against 
penetrating horns, backed by the fury of the Durham. 

I think the hypothesis that immunity from disease is 
acquired by the interactions of tissue-cells and the patho- 
genic organisms of disease is one that can explain all phe- 
nomena of disease in this relation. Natural selection is one 
of the verve causae in nature. To further establish this hy- 
pothesis, it is, of course, necessary to examine other hy- 
potheses to find if they will stand the test. 

The hypothesis that a chemical compound is formed by 
the micro-organisms, and left in the tissues, which prevents 
their further action — as alcohol kills yeast, or acetic acid 
kills Mycoderma aceti, and as the excremental products of all 
.bacteria destroy the organisms which produce them — is cer- 
tainly unable to explain anything. If it were true, nothing 
could be easier to find in the tissues, and no such thing has ' 
been found. That destruction of certain tissues for which 
the parasite has an affinity gives the immunity is destroyed 
as an hypothesis for the reason that such tissues are repaired 
by the recovery of. the patient, in all cases. 

The oxygen theory ^of Dr. Salmon is too narrow a con- 
ception for the occasion, and there are no verifications to 
sustain it. Who can imagine that tubercle bacilli in the 
lungs can consume the oxygen inhaled so rapidly that there 
is not a sufficient supply for the lungs ? The inhalation of 
oxygen is found to do harm in consumption as well as many 
other diseases. If Dr. Salmon's hypothesis is true, the in- 
halation of oxygen ought to not only cure, but prevent all 
diseases of zymotic origin. Let us transfer the terms of Dr. 
Salmon's proposition to another case. The terms are these 
as quoted from Dr. Eccles's paper : " The poison of the 
microbes intoxicates the cells. Retarded function [of the 
cells] allows oxygen to increase in the circulation, thus 
facilitating their gaining a foothold. Recovery is due to the 



ability of the cells to resist the poison [this is true, and all 
there is of it in relation to recovery and also to immunity], 
use up their own oxygen, and so asphyxiate the microbes." 
Dr. Salmon has not made an estimate relating to the venti- 
lation of the human body with oxygen and the relative 
amount consumed by microbes and cells, which is necessary 
as a factor of this problem. It is quite likely that oxygen 
cuts no figure in the problem except as a necessary ante- 
cedent to all phenomena of life — microbic and human. I 
will transfer the terms of this problem to another case like 
it. Suppose a man and dog are confined in a well-ventilated 
room, and the dog, being hungry, attempts to kill the man 
to eat him. It is necessary to kill him first. The dog at- 
tacks the man, and, getting him by the throat, chokes him. 
Now the retarded function [of the man] allows the oxy- 
gen in the room to accumulate or increase in the room, thus 
allowing the dog to maintain his position. Now, if the 
man recovers, it is due to his ability to overcome the dog's 
hold on his throat, and then to use up his own oxygen, and 
by so doing asphyxiate the dog — by using all the oxygen 
himself. Dr. Salmon admits the solution of the question 
by natural selection when he says the " recovery is due to 
the ability of the cells to resist the poison." Immunity is 
also due to the same fact. The oxygen theory is therefore 
only a rider to the true solution ; very much such a rider, 
too, as Mazeppa was, in so far as ability to guide the horse 
is concerned. Dr. Salmon's theory assumes that the mi- 
crobes are in the body by accident, and destroy the cells, 
not to consume them, but in order to rob them of oxygen. 
The position of the microbe is that of offense rather than 
of defense. 

It is evident that we can substitute nitrogen or bile in 
place of the oxygen in this problem and do no violence to 
the sense or the results. What prompts the dog in the 
assault is the necessity for food. The same is true Avith the 
microbes. The dog does not poison his prey, because he 
kills it mechanically ; but this does not change matters any. 
The man may have some knowledge of dog-combat, gained 
from former experience, or may not ; but, if he saves his 
life, it is not because he uses the oxygen in a well-ventilated 
room himself at the expense of the dog, but because he 
knows or learns a method of successful physical resistance 
to the dog. If he learns a specific method of resistance to 
the dog from actual combat, as punching the dog's eyes, or 
choking him, in time, doubtless, he will tell his children the 
method, and so transmit the gift by heredity to them, and 
the dogs will all be obliged to take up with Mother Hub- 
bard, who, by this time, should have a bone or two in her 
cupboard. 

The cell and microbe and man and dog present prob- 
lems of warfare the terms of which are parallel and alike. 
The combat in each case is due to that great biological law 
which underlies all the sin of this world, which is that liv- 
ing things are adapted to each other as a food-supply, and 
the fittest will swallow the other. When Eve ate the apple, 
the probable extent of the sin was in the consumption of 
other living material. This would have been a guileless 
world if all living things had been created to take their diet 
from the inorganic world, and men "at meat" could sit 



70 



BOOK NOTICES.— CORRESPONDENCE. 



[N. Y. Mbd. Joch., 



down to a table spread with samples from the inorganic 
world — nitrogen, ammonia, carbonic acid, salines, and water, 
instead of quail on toast, oysters, eggs, milk, lamb, chicken, 
etc. 

In both these cases of man and dog, cell and microbe, 
we find corresponding and like general principles which 
explain all such cases. These combats result in variation 
of all organisms concerned. No case can be Vientioned 
which can not be explained by this generalization. The 
variation consists in an organic change with corresponding 
functions in all organisms concerned. If the cells gain an 
immunity from further attacks of microbes, it is because 
variation, acquired by actual combat, has given them a 
power of physico-vital resistance to poison, which they 
maintain until the forces of atavism have taken this power 
away. The phenomena of immunity, in point of duration, 
correspond directly with the forces of variation and atavism. 
That we are unable to know the character of the variation 
and atavism which gives a cell the power to resist a poison, 
or makes it susceptible to poison, proves nothing against 
the hypothesis, but only proves that, for physical reasons, 
the verification is difficult. 

But, while on the subject of immunity from disease, it is 
well to take a look at it from the standpoint of hygiene. 
The study of physically acquired immunity from disease is 
interesting oidy as a means or end of scientific accomplish- 
ment, and is of no great practical value. The science which 
can give a man immunity from disease only by subjecting 
him to an actual combat for life with his personal enemies 
is a science which is not worthy of being called hygienic. 
Why not destroy the microbe before it attacks the man, 
and gain the immunity by this means? Immunity gained 
through actual disease reminds one of the subject who went 
to his king and complained that his enemy had threatened 
to kill him. The King said : " Don't worry, my man ; if 
he kills you I will have him beheaded within an hour." 
The man tried to appear comforted, but finally ventured to 
suggest that the best preventive would be to behead the 
enemy an hour before he made the threatened assault. 

Immunity from disease, gained by costly combat with 
poisonous microbes, is the method of nature without in- 
telligence. The method is not worth imitation except pro- 
visionally. The study of the microbe in this relation is 
useful only as it will give the knowledge of the methods 
which can compass its destruction while it is yet outside the 
body and before disease is produced. 



jtooh ftotites. 

An Introduction to Pathology and Morbid Anatomy. By T. 
Henry Green, M. L). Lond., etc. Fifth American from the 
sixth revised and enlarged English edition. With one hun- 
dred and fifty engravings. Philadelphia: Henry G. Lea's 
Sun & Co., 1884. Pp. xx-17 to 481, inclusive. 
An extended review of such a well-known book is unneces- 
sary. We had already regarded the work as a model of its 
kind, and the author's assurance that he believes the present 



edition to be fully up to date will be received as sufficient proof 
that nothing of importance has been omitted. The reader will 
find several additions to the last edition. The introductory 
chapter has been remodeled, a new chapter on tumors appears, 
and the subjects of septicaemia and pyaemia are presented in an 
unusually clear and compact form. For these improvements 
the author expresses his obligations to his surgical colleague, 
Mr. Stanley Boyd. The closing chapter, upon " The Vegetable 
Parasites," appears beneath that gentleman's name, and is a 
thorough and exhaustive resume of the subject. Appended to 
this section is a brief description of the different methods of 
cultivating and staining micro-organisms. In stating that the 
book is up to the time, we need not add that the bacilli of 
tuberculosis, cholera, and leprosy, and the micrococci found in 
erysipelas, pneumonia, scarlatina, typhus, and gonorrhoea, all 
receive due notice. The book has been most carefully revised, 
and bears upon every page the marks of that care and accuracy 
which have won for it an international reputation. 

BOOKS AND PAMPHLETS RECEIVED. 

A Text-Book of Medical Physics. For the Use of Students 
and Practitioners of Medicine. By John G. Draper, M. D., LL. 
D., Professor of Chemistry and Physics in the Medical Depart- 
ment of the University of New York, etc. With Three Hun- 
dred and Seventy - seven Illustrations. Philadelphia: Lea 
Brothers & Co., 1885. Pp. 733. 

A Manual of Human Physiology, including Histology and 
Microscopical Anatomy ; with Special Reference to the Re- 
quirements of Practical Medicine. By Dr. L. Landois, Profess- 
or of Physiology and Director of the Physiological Institute, 
University of Greifswald. Translated from the Fourth German 
Edition, with Additions, by William Stirling, M. D., Sc. D., 
Regius Professor of the Institutes of Medicine, or Physiology, 
in the University of Aberdeen. With 318 Illustrations. Vol. 
II. Philadelphia: P. Blakiston, Son & Co., 1885. Pp. xvi- 
515 to 1184, inclusive. [Price, $5.50.] 

Berlin as a Medical Centre. A Guide for American Practi- 
tioners and Students. By Horatio R. Bigelow, M. D., Member 
of the American Medical Association, etc. [Reprinted from the 
"New England Medical Monthly."] 

On the Severe or so-called " Uncontrollable " Vomiting of 
Pregnancy. By Graily Hewitt, M. D., F. R. C. P., etc. [Re- 
printed from the " Transactions of the Obstetrical Society of 
London."] 

Report of the Board of Managers of the Pennsylvania Hos- 
pital, 1885. 



Corrfsponbenre. 

LETTER FROM ST. LOUIS. 

Railway Sanitation. — The Inspection of Meat. — The Closure of 

Wells. 

St. Louis, June 30, 1885. 

Among the matters of importance to the public in regard 
to general sanitation and of special interest to our profession 
as custodians of the public health are the questions, What can 
be done by our railroad companies, not only for the health of 
their employees, but to secure that their buildings and rolling- 
stock shall be kept in a thoroughly sanitary condition? and 
then, What, are they doing? 

For some time past the Missouri Pacific Railway System has 
made provision for the efficient and skillful treatment of em- 



July 18, 1885.] 



CORRESPONDENCE. 



71 



ployees, who are injured or become sick in its service, by the 
establishment and maintenance of a large hospital well situated 
and with abundant room, and with the greatest facilities for 
giving those who are entitled to it the very best care that is 
possible. 

Similar arrangements have been made by the Wabash Sys- 
tem, although that organization has not established a large hos- 
pital here. The surgeons of that company have formed a 
medical society and hold regular meetings, at which papers are 
read and discussed on such topics as are of special interest to 
them. 

Another step has just been taken by the Missouri Pacific 
System. A circular has just been issued by Vice-President 
Hoxie in which is expressed the desire of the managers to 
place the property of the companies comprised in this system 
in good sanitary condition, and attention is called at the same 
time to the importance of such measures to the welfare and 
prosperity of the employees. The managers express their in- 
tention of hearty co-operation with all State and local boards 
of health with which they may come in contact, and enjoin 
similar hearty co-operation upon all concerned. 

Dr. W. B. Outten, chief surgeon, is placed in charge of all 
matters pertaining to the sanitary interests of the roads, and 
all officers and employees are instructed to carry out any rules 
and directions that may be issued by him. Sanitarians in the 
East and West will await with interest the publication of Dr. 
Outten's rules and directions, as the subject of railway sanita- 
tion is almost a new one, and the chief surgeon of a system that 
operates over six thousand miles of track through such a coun- 
try as that in which these roads lie has an opportunity and a 
responsibility such as fall to but few men. 

Another matter of considerable local sanitary interest is 
attracting more or less attention in the papers now. For some 
years the citizens of all other leading cities of our country have 
been more or less effectively protected from the dangers at- 
tendant upon the use of diseased or tainted meats by systems of 
meat inspection which, in so far as they were faithfully adminis- 
tered, rendered it impracticable, or at least financially dangerous, 
to offer spoiled meats for sale for human food. Strange as it 
may seem, the city of St. Louis has had no such system of in- 
spection, and, as a result, it has come to be the fact, as one of 
the daily papers said, that " St. Louis is the great dumping- 
ground for all the diseased and damaged meat raised in the 
West." Last winter an ordinance was passed and an appro- 
priation was made by which a very rigid inspection was estab- 
lished and enforced to the great advantage of the citizens and 
to that of honest dealers as well, but to the cost and extreme 
discomfiture of those who had been wont to make money from 
the poor by selling them diseased or tainted meats. The pro- 
vision for this, however, was only limited, and when the time 
came for making a new appropriation so that the same protec- 
tion might be continued, to their shame be it said, a sufficient 
number of the House of Delegates were found to cast their 
votes against the appropriation to defeat it, and, consequently, 
during the summer weather we are without the needed protec- 
tion, and unscrupulous butchers and dealers know that our city 
makes no provision for the protection of its citizens in this 
regard . 

Of course, this danger is one to which the poor are in a 
peculiar degree exposed. The wealthier citizens purchase cost- 
lier meats from dealers who can not afford to risk their reputa- 
tion by selling bad meat, while the poorer classes buy from 
those who have little or nothing at stake, and who too often 
care for naught except to make what gain they may, even at 
the peril of health or life to the unsuspecting victim. A bill 
has now passed the Council, and will come before the House of 



Delegates this week, which makes provision for the renewal of 
efficient meat inspection. 

A good deal of time has been taken up at the meetings of 
the city Board of Health for some weeks past in considering 
the subject of closing wells. An ordinance was approved March 
25th last, to which I have referred in a former letter, which 
made provision for the closing of wells that should be found on 
examination to contain more than six grains of chlorine to the 
gallon of water. The wells of the city are divided into two 
classes, viz., those which are in the public streets or sidewalks, 
and those on private premises. The first class, as a rule, are 
situated at street corners, and have been sunk by the owners or 
lessees of saloons or groceries where beer and liquors are sold, 
for the purpose of attracting custom from teamsters and others 
who, while securing a free drink for their horses, will step in- 
side and spend five or ten cents for a drink of what may be a 
little more dangerous in its effects than the polluted water of 
the wells. Many of these wells were resorted to by neighbor- 
ing families because the water was clear and cool. 

By the ordinance referred to, all wells located in the public 
streets which ^should be found to contain six or more grains of 
chlorine to the gallon were abolished, and, on a certificate to 
that effect from the Board of Health, it was made the duty of 
the Street Commissioner to cause them to be filled at the public 
expense. At a meeting of the Disbursing Committee of the 
Sanitary Aid Association this week it was reported that, of one 
hundred and sixty-one wells on public streets which had been 
condemned, one hundred and fifty-two had been filled. There 
was a good deal of opposition to the enforcement of this sec- 
tion of the ordinance on the part of the saloon-men, who felt 
that the closing of their pumps would seriously interfere with 
their business. Besides, it was argued that it would cause much 
suffering to animals. One man was very anxious to be allowed 
to retain his well, with the stipulation that the handle should 
be removed from the pump and be kept within the saloon, and 
only be taken out to pump water for horses and stock ; in no 
case to pump water for cooking or drinking by human beings. 
The Board of Health could see no way to insure its really 
being used only for cattle, and declined to make any such modi- 
fication of the order. A case was made and carried to the Su- 
preme Court, which last week rendered a decision sustaining 
the ordinance and the action of the Board of Health in enforc- 
ing it. 

The action in regard to the wells on private property is by no 
means so simple as that in regard to those on the public streets. 
There are several complications which do not arise in dealing 
with the water question in Eastern cities. I shall speak of these 
directly. The ordinance declares all wells located on lots of land 
fronting on streets, avenues, or alleys, in which the public water- 
pipe is laid, to be nuisances, except those tchich are used exclu- 
sively for manufacturing or stable purposes or for watering stock, 
or which may be proved, to the satisfaction of the Board of 
Health, to contain pure water. [Italics mine.] "Any water in 
wells which shall contain six grains or more of chlorine to a 
gallon of water shall be deemed to be impure." 

One of the first cases which came up before the Board of 
Health under the section relating to wells on private property 
was that of a woman who used the water for washing and 
rinsing clothes. The question at once arose whether such a well 
was to be excepted from condemnation under the plea that this 
was to be considered as using the water for manufacturing pur- 
poses. 

After some discussion, inasmuch as the board were informed 
that a case had been made up so as to secure a ruling of the 
Supreme Court as to the whole scope of the law, it was re- 
solved to hear the statements of the various well-owners as to 



CO RRESPONDENCE. 



[N. Y. Med. Jodr., 



the" use made of the water, and to delay making any final 
order until the decision of the Supreme Court should be ren- 
dered. It seems now that a good deal of time has been lost, as 
the case that was carried up and the decision of the Court con- 
sider only the wells in public streets. 

Of course, in dealing with these cases, the Board of Health 
has encountered the usual prejudice against innovation which 
is always met with. There has been the usual number of old 
residents who " have drunk the water from that well for thirty 
years, and there has never been a case of sickness in the house 
the whole time." There have been parents whose sick children 
have been refreshed when fevered by the cool water from that 
well, and have got well, and who, therefore, can not be con- 
vinced that the water is unwholesome for well people. 

There have been people who have lived in the same locality, 
and have drunk water from the same well during two cholera 
seasons, and who therefore refuse to take alarm at the statement 
that the water contains from twelve to twenty grains of chlo- 
rine to the gallon. All these cases are only repetitions of the 
experiences which occur wherever well-filling is taken up as a 
sanitary precaution." 

But two difficulties exist here which, I think, are somewhat 
peculiar. First, as everybody knows who has ever visited St. 
Louis, our water is by no means clear. At its best it holds in 
suspension a sufficient quantity of fine impalpable matter, of a 
sort of yellow-ochre color, which characterizes the water of the 
Missouri Kiver, from the point where the Yellowstone River 
empties into it, to give it the appearance of lemonade; at other 
times it contains enough earth to give it the color of cafe au 
lait. On allowing it to stand for some hours, all, or nearly all, 
of this solid matter will settle, and clear water can be obtained 
for washing and rinsing clothes. (For drinking purposes most 
people prefer it "in its rich natural state.") As a matter of 
fact, however, most of those who take in washing, and are de- 
pendent upon their laundry-work for their livelihood; have no 
facilities for settling the river water, though a good many of 
them have wells from which they have drawn water for rins- 
ing. It certainly would be a hardship to deprive such people 
of the opportunity so to use the water, and yet in nine cases 
out of ten where they use the water for this they will also 
use it for drinking, as it is so much cooler than the hydrant 
water. 

Another difficulty that has been encountered is the fact that, 
especially in German neighborhoods, there is a prevalent opinion 
that salting a well will purify the water and make it whole- 
some, as well as keep it free from various bugs. Therefore, in 
a good many cases, it has proved that wells which contained a 
very large amount of chlorine, and, consequently, were supposed 
to be badly polluted by sewage, really owed the chlorine to salt 
that had been thrown in by the owners for the purpose of pre- 
serving the water from contamination. 



LETTER FROM WASHINGTON. 

The District Medical Society.— The City's Water-Supply .— The 
International Medical Congress.— The Hospitals.— Political 
Appointments. 

Washington, July 12., 1885. 
There has been very little of general interest here since the 
adjournment of Congress, so far as medical matters are con- 
cerned. 

The District Medical Society adjourned for the summer last 
Wednesday. The meetings have been well attended through the 
year, and interest has been maintained far into the hot term by 
the discussions on Asiatic cholera and the water-supply of the 
city. The water-supply question is not yet settled, and there 



has seemed to be a disposition to make it rather a political than 
a scientific matter, owing to the apparent criticism of the authori- 
ties involved in the discussion. Some [joints were settled : First, 
that there was a waste from the canal into the source of the 
conduit at the river, and, second, that the drainage-basin into the 
reservoir had included farmers' outhouses, privies, and pig-pen 
refuse. All this has been corrected, and there is now a senti- 
ment of relief. As usual, those responsible for. this not very 
cheerful state of affairs at first denied the existence of the evils 
as alleged, and later on abused those engaged in the discussion 
of them. The water-supply is still inadequate, and a new con- 
duit and an additional reservoir are being constructed. This 
will furnish an abundance of water for a great many years to 
come. It is stated that a sewer-pipe from the hospital on the 
Soldiers' Home reservation passes directly under the new reser- 
voir, and much apprehension is felt by those who know how 
easy it is for a sewer-pipe to become loose at its connections 
from the escape of gases and fluid through the cement. This 
prospective evil admits of a practical remedy by changing the 
direction of the sewer. 

Before adjournment the society re-elected its former officers, 
Dr. W. W. Johnston, president, and Dr. Thomas McArdle, sec- 
retary. Those gentlemen who were originally appointed on the 
International Medical Congress, and retained by the new com- 
mittee, have resigned. There was no local grievance. 

Dr. J. F. Hartigan, of this city, now in London, is expected 
to return on the Germanic, which will sail about the 27th of 
August. The doctor has been hard at work, and has an appoint- 
ment every day at the Soho Square Hospital and at the East 
London Children's Hospital. 

The rage for incrimination and investigation reached Wash- 
ington some time since, but seems to have about expended itself. 
The Children's Hospital imbroglio, that at the Columbia Hospi- 
tal, and the Wales Court-Martial are the principal topics of 
medical gossip. In the former case one gentleman, long con- 
nected with the hospital, has resigned ; at the Columbia Hospi- 
tal, Dr. Murphy, the physician in charge, has been exonerated. 

Dr. R. S. L. Walsh has resigned from the consulting board 
of the Providence Hospital, and has accepted a position as one 
of the attending physicians to the Garfield Hospital. 

The scramble that took place between the hospitals last year 
for the appropriation of fifteen thousand dollars, set apart by 
Congress for hospital purposes, has been happily avoided this 
year by the appropriation of a specific sum for each. 

Dr. T. I. Chew has been appointed physician to the alms- 
house hospital, vice Dr. T. P. C. Hazen, resigned. 

With the coming in of the new administration a race began 
for the position of health officer of the district, now held by Dr. 
Smith Townshend. As the present commissioners were decid- 
edly friendly to Dr. Townshend, and as he has had the support 
of his brother, a member of Congress from Illinois, the various 
applicants have not up to this time received much encourage- 
ment. With the forthcoming change in commissioners it is 
said a change will be made. 

The Board of Pension Examiners has been reorganized to 
correspond to the views of the politicians by removing Dr. Rob- 
ert Reyburn. The dissatisfaction at the new arrangement has 
been so great that two boards have been formed. It is sincerely 
to be hoped that America may be enlightened and patriotic 
enough some day to allow honest and efficient medical officers 
to remain without reference to changes of the administration. 
If the incumbent is unfitted or unworthy, that would be abun- 
dant reason for making a change. Such a reason would not be a 
political one, but the spoils system, with its outrageous abuses, 
seems now, as in the past, to be the most tenderly cherished 
tenet of political faith. 



July 18, 1885.] 



LEADING ARTICLES. 



73 



THE 

NEW YORK MEDICAL JOURNAL, 

A Weekly Review of Medicine. 

Published by Edited by 

D. Appleton & Co. Frank P. Poster, M. D. 

NEW YORK, SATURDAY, JULY 18, 1885. 

THE INTERNATIONAL MEDICAL CONGRESS. 
It was with expressions of anything but hopefulness that we 
wrote last week of the prospects of the Congress, and we were 
particularly emphatic in the view that we had insisted upon 
from the outset, that the entire responsibility for the threatened 
disaster rested upon the American Medical Association, and not 
upon its new committee. For a time it seemed as if we were 
almost alone in the advocacy of this view, but since our last 
issue was published several things have happened which we 
interpret as going to show that the responsibility of the Ameri- 
can Medical Association is getting to be more and more recog- 
nized. 

The comments of some of our contemporaries are indicative 
that they at least are beginning to recognize it, and it is spe- 
cially noteworthy that the " Medical Bulletin," edited by Dr. 
Shoemaker, takes considerable pains to show that the commit- 
tee acted under such instructions that it could not do otherwise 
than as it did. A most telling piece of testimony in the same 
direction comes to us in the shape of a letter from Dr. Howard, 
of Baltimore, which we publish elsewhere in this issue. Ex- 
plaining why he declined to sign the Baltimore resolution, Dr. 
Howard puts himself squarely in accord with its signers on the 
real issue, and explicitly states that he concurs with the Boston 
resolution, which expressly fixes the responsibility upon the 
association. It is quite possible that there are others who 
are perfectly willing to express themselves to this effect, but 
hesitate to attach their names to anything which may seem 
like a reflection upon the members of the committee as indi- 
viduals. 

If the association can be made to feel that its action in 
this matter meets with very general condemnation, there is 
some hope of its being rescinded in St. Louis next year. If the 
status quo should then be restored, there would still be more 
than a year in which to prepare for the Congress, and the gen- 
tlemen whose further services in its organization have been 
lost for the time being, in consequence of their haviDg resigned 
from the committee in disgust, might perhaps be induced to 
reconsider their determination. It seems now, therefore, that 
a break may be made in the impenetrable hopelessness of a 
week ago. But the only way to bring the American Medical 
Association to its senses is for those of the committee's nomi- 
nees who have the success of the Congress more at heart than 
their own tenure of office to continue the good work which has 
been begun in Philadelphia, Boston, Baltimore, and Washing- 
ton. These cities happen to be situated in the East, but it is 
assuredly by no sectional feeling that they have been led, and 
we think our friends in other quarters of the country make a 
great mistake if they so interpret the action taken. It has un- 



questionably become the duty of every well-wisher of the Con- 
gress, no matter where he may live, to decline any participation 
in the emasculated affair which its present organization must 
necessarily lead to. The impression thus made upon the Ameri- 
can Medical Association, together with the unusual care which 
we hope to see taken in the choice of delegates to its next 
meeting, may result in the regeneration of that body. This is 
a matter of even greater importance than the success of the 
International Medical Congress. 

BROOKLYN AND THE INTERNATIONAL MEDICAL CONGRESS. 

We have heretofore given the new committee on the Inter- 
national Medical Congress the credit of having done as good 
work as seemed to be possible under the stringent restrictions 
imposed upon it by the New Orleans meeting. Our attention 
has lately been called to the fact of the very few appointments 
that fell to the city of Brooklyn — only three in number, while 
Philadelphia has forty-seven, Boston thirty, Baltimore twenty, 
and Washington (exclusive of army and navy surgeons) four- 
teen. In view of the stress that the New Orleans meeting laid 
on the principle of geographical representation, and bearing in 
mind that Brooklyn has a population of nearly three quarters 
of a million — larger, therefore, than that of either of the other 
cities mentioned, except Philadelphia — it is difficult to avoid the 
thought that the committee lost sight of the geographical prin- 
ciple in this particular instance. The principle is one which 
we consider it absurd to proceed upon in such a matter, and 
we should favor the best possible list of officers, even if every 
one ofthem lived in an obscure village ; but, if it was to be car- 
ried out, it should have been done equably. Especially should 
such a glaring exception not have been made with regard to a 
city where so much is done to advance medicine as in Brook- 
lyn. To be sure, the three appointees from that city, Dr. 
Hutchison, Dr. Squibb, and Dr. Raymond, are quite capable 
of making an excellent showing for Brooklyn, in case they at- 
tend the Congress, but they might appropriately have been re- 
enforced by such men as Armor, Bell, Butler, Byrne, Fowler, 
French, Gray, Hutchins, Jewett, Mathewson, Pilcher, Rock- 
well, Segur, Sherwell, Skene, Speir, Thayer, Westbrook, and 
Wight — men whose names are known wherever current medi- 
cal literature is read, and who are recognized leaders in the 
several branches of medicine to which they have devoted them- 
selves. 

NEWS ITEMS, ETC. 

Infectious Diseases in New York.— We are indebted to 
the Sanitary Bureau of the Health Department for the following 
statement of cases and deaths reported during the two weeks 
ending July 14, 1885 : 



DISEASES. 


Week ending July 7. 


Week ending Jul; 14. 


Cases. 


Deaths. 


Cases. 


Deaths. 




0 


0 


1 


• 0 


Typhoid fever 


13 


4 


9 
31 


2 




35 


5 


9 




4 


4 


4 


3 




66 


12 


55 


10 




41 


21 


55 


24 




3 


0 


2 


1 



74 



MINOR PARAGRAPHS. 



[N. Y. Med. Jodh.. 



Small-pox. — A ship which arrived at this port last week 
from Liverpool had lost two of her crew with small-pox during 
the voyage. The vessel was quarantined and fumigated. Press 
dispatches allude to an epidemic near Creston in Iowa. It is 
stated that during the three weeks ending on Monday, the 13th 
inst., thirty-two deaths occurred from the disease in Montreal, 
fifteen of which took place during the last week of the three, 
and that six new cases were reported on the 13th. As will be 
seen by the report of infectious diseases, five cases were discov- 
ered in New York during the fortnight ending on Tuesday, one 
of which proved fatal. 

New York State Medical Association, Fifth District 
Branch. — The first annual meeting of the Fifth District Branch 
will be held in Brooklyn, on Tuesday, October 13, 1885. There 
will be a morning and afternoon session. All fellows desiring 
to contribute to the meeting, either by reading papers, notes, or 
communications, or by exbibiting specimens, are respectfully 
invited to notify the secretary to that effect at their earliest 
convenience. 

J. C. Hutchison, M. D., President. 
E. H. Squibb, M. D., Secretary, 30 Doughty Street, Brooklyn. 

The International Medical Congress and the Medical 
Profession of Washington.— At a meeting of medical gentle- 
men held in Washington, D. C, July 11, 1885, the following 
preamble and resolution were adopted : 

Whereas, Certain changes have been made in the constitu- 
tion and organization of the Ninth International Medical Con- 
gress which seem to us unwise, injurious, calculated to bring 
the profession into disrepute, and to endanger the success of the 
Congress, therefore 

Resolved, That we, the undersigned, decline to hold any 
position under the said Congress as now organized. 
Joseph Taber Johnson, M. D. S. C. Busey, M. D. 
W. W. Johnston, M. D. H. C. Yarrow, M. D. 

Swan M. Burnett, M. D. A. F. A. King, M. D. 

B. F. Pope, M. D., U. S. Army. Frank Baker, M. D. 
E. Carroll Morgan, M. I). D. Webster Prentiss, M. D. 

J. Ford Thompson, M. D. S. O. Richey, M. D. 

D. L. Huntington, M. D., U. S. Army. 

The International Medical Congress and the Council of 
the New York State Medical Association.— The following 
resolution, recently adopted, reached us too late for insertion in 
last week's issue : 

Resolved, That the Council of the New Y T ork State Medical 
Association respectfully recommend to the Committee of Ar- 
rangements for the International Medical Congress the following 
modification of the rule by which the American membership of 
the Congress is to be constituted, to wit : That the American 
membership of the Congress be constituted of delegates who shall 
be entitled to participate in the business and scientific proceedings, 
and of members who shall be entitled to participate only in the 
scientific proceedings of the Congress ; that the delegates may 
be appointed by the American Medical Association and by State 
and local organizations in affiliation therewith in the propor- 
tion of one delegate for every ten or fraction of ten members of 
the organizations thus represented ; that members of the regu- 
lar medical profession of the United States may become mem- 
bers of the Congress by registering their names as such and by 
taking out tickets of admission. 

The University of Vermont. — It gives us pleasure to insert 
the following deserved tribute to Dr. Wright: 

" The Medical Faculty of the University of Vermont, having 
been unable to retain permanently the services of Professor J. 



W. Wright, of New York, as professor of clinical surgery, beg 
leave, in accepting his declination of the position, to extend to 
him, both personally and officially, their grateful appreciation 
of the eminent service he has already rendered the University 
of Vermont by his course of Lectures on Surgery, just con- 
cluded. 

" As a skillful operator and a scholarly lecturer, both didactic 
and clinical, Professor Wright has ^iven universal satisfaction. 
In leaving the Medical Department of the University of Ver- 
mont, Dr. Wright carries with him the best wishes of the Medi- 
cal Faculty and of the corporate authorities of the Univer- 
sity." 

M. II. Buckham, President, University of Vermont. 
A. F. A. King, 
A. P. Grinnell, 
[Signed.] R. A. Witthaus, {> Medical Faculty. 

J. Henry Jackson, 
Henry D. Holton, 

A New Hospital, endowed by the late Mr. Robert A. 
Packer and named after him, was opened at Sayre, Pa., on 
Monday of this week. The building was formerly Mr. Packer's 
residence. 

The late M. Gueneau de Mussy.— According to the " Union 

medicale," a subscription has been started to obtain funds for 
a bust of the late M. Noel Gueneau de Mussy, to be placed in 
the Hotel-Dieu. 

Army Intelligence. — Official List of Changes in the Sta- 
tions and Duties of Officers serving in the Medical Department, 
United States Army, from July It, 1885, to July 11, 1885 : 
Havard, Valery, Captain and Assistant Surgeon. Assigned to 
duty at Fort Wadsworth, New Y'ork Harbor. S. 0. 140, 
Department of the East, July 2, 1885. 
Wyetii, M. C, First Lieutenant and Assistant Surgeon. As- 
signed to duty at Fort Wayne, Michigan. S. O. 140, Depart- 
ment of the East, July 2, 1885. 
Powell, Junius L., Captain and Assistant Surgeon. Ordered 
from Department of the East to Department of the Missouri. 
S. 0. 155, A. G. 0., July 9, 1885. 
Birmingham, Henry P., First Lieutenant and Assistant Surgeon. 
Ordered from Department of the Missouri to Department of 
the East. S. O. 155, A. G. O., July 9, 1885. 

Naval Intelligence. — Official List of Changes in the Medi- 
cal Corps of the United States Navy during the week ending 
July 11, 1885. 

Byrnes, J. C, Passed Assistant Surgeon. Detached from the 
Powhatau for duty at Navy-Y'ard, Norfolk, Va. 

Cordeiro, F. J. B., Assistant Surgeon. To the Powhatan as re- 
lief of Passed Assistant Surgeon Byrnes. 

Curtis, L. W., Assistant Surgeon. To Philadelphia for exami- 
nation preliminary to promotion. 

Drennan, M. C, Surgeon. Placed on waiting orders. 

Fitzsimmons, P., Surgeon. Duty on Receiving Ship Franklin, 
Norfolk Navy-Y T ard, continued until July 1, 1886. 

Society Meetings for the Coming Week : 

Monday, July 20th: Chicago Medical Society; Hartford, Conn., 
City Medical Association. 

Tuesday, July 21st: New York Academy of Medicine (Section 
in Theory and Practice of Medicine) ; Medical Societies of the 
Counties of Kings and Otsego (Cooperstown), N. Y*. ; Og- 
densburg, N. Y T ., Medical Association. 

Thursday, July 23d : New Y T ork Academy of Medicine (Sec- 
tion in Obstetrics and Diseases of Women and Children) ; 
New York Orthopaedic Society. 



July 18, 1885.] 



LETTERS TO THE EDITOR. — PR 0 GEE DIN OS OF SOCIETIES. 



75 



fetters to tlje <£oitor. 



THE RESPONSIBILITY FOR THE INTERNATIONAL MEDICAL 
CONGRESS MUDDLE. 

Baltimore, July 13, 1885. 
To the Editor of the New York Medical Journal: 

Sri?: I ask leave to say that I declined signing the resolutions 
in regard to the International Medical Congress that were for- 
warded from this city, and published in your journal of the 11th 
nst. (page 45), because they place the blame for the lamentable 
state of affairs entirely on the action of the new committee at 
Chicago, while, as it seems to me, that committee acted simply 
in accordance with the stringent restrictions imposed upon it 
by the unwise and revolutionary conduct of the American Medi- 
cal Association at New Orleans in nullifying the action of the 
first committee, and thus opening the Pandora's box of the 
countless evils now agitating the American medical profession. 

The resolutions passed at the meeting of the medical men of 
Boston, and published on the same page of your journal, meet 
with my cordial concurrence. 

With great respect, 

W. T. Howard. 



|)roceebtncrs of Societies. 

NEW YORK ACADEMY OF MEDICINE. 
Meeting of June 4, 1885. 
The President, Dr. A. Jacobi, in the Chair. 

Contagious Ophthalmia in some of the Orphan Asylums 
and Residential Schools of New York City. — Dr. Richard 
H. Derby, the author of the paper, said it appealed to the 
hearer on the threefold ground of philanthropy, medicine, and 
social science. He referred to the report made to the County 
Medical Society in 1884 concerning the condition of the eyes 
of the inmates of three institutions in this city, and stated that 
since then twenty-four other institutions had been visited, con- 
taining in all 7,440 inmates. After describing the appearances 
of the eyes of one suffering from contagious ophthalmia, Dr. 
Derby said that in the first institution visited 24'5 per cent, of 
all the inmates had contagious conjunctivitis; in the second, 
488 out of 1,586; in the third, 111 out of 782 ; in the fourth, 
93 out of 188. The number of cases in this institution had de- 
creased since his first visit, after which each of the inmates had 
been given his own towel and brush, etc., and the general 
hygienic state had been improved. The proportion of cases in 
several other institutions was then mentioned. 

It was not the object of the paper to consider in detail the 
various conditions which led to the development of contagious 
eye diseases in the asylums visited. The part played by imper- 
fect quarantine, bad lavatories, overcrowding, bad hygiene— all 
these had been discussed elsewhere. His purpose would have 
been attained if he drew attention to the fact that in the 
asylums of our cities, where children in large numbers were 
housed, being taken from unhealthy homes, there existed to an 
alarming extent a disease fraught with danger to the eyes of all 
assembled there. It would be noticed that in the institutions 
visited the larger number of cases of contagious ophthalmia 
existed where the inmates used the towels indiscriminately, 



washed in the same basin or trough, and slept together, and 
also where there was general bad hygiene. The disease might 
be present without attracting the attention of the attendants. 
In too many instances it went on insidiously, undermining the 
health of the eyes, until finally an acute attack took place, and 
gave rise to an epidemic of contagious ophthalmia. We had 
just seen that of the 7,440 inmates of institutions visited, 1,428, 
or 1919 per cent., had contagious conjunctivitis, or nearly one 
in every five. Besides, in several of the institutions it was the 
custom to send the worst patients to their homes, where they 
might seek treatment outside, thus rendering probable the fur- 
ther spread of the disease among the neighbors. The parents 
of such children were not properly situated for carrying out 
effectual treatment, and were unable to care for them in a suit- 
able manner. In many cases it was to the advantage of the 
institution to receive as many inmates as possible, and thus 
overcrowding was encouraged. 

The Board of Health should be notified of every case of con- 
tagious ophthalmia in any of the institutions, and accommoda- 
tions should be provided for isolating the patient until he was 
no longer capable of communicating the disease. There were 
enough cases of contagious ophthalmia in the institutions at 
present to fill a hospital devoted to their isolation and treat- 
ment. It behooved the members of the Academy of Medicine 
to make emphatic protest against the continuance of the present 
state of things. 

Dr. H. Knapp said the statements of the speaker ought in 
no way be underrated. He had been connected with a number 
of institutions as ophthalmic surgeon, and knew that in a num- 
ber of them, and perhaps at certain periods in all of them, con- 
tagions ophthalmia existed. Sometimes the spread of the dis- 
ease had been so great that the authorities of the institutions 
were forced to close them and to farm the inmates out. But 
he could, on the other hand, state that in many of the institu- 
tions the greatest care was taken to stamp out the disease. He 
mentioned the Catholic Protectory in particular, where, when 
an epidemic broke out, they called physicians and sought in 
every way possible to stamp out the disease, and the spread of 
the blennorrhoea was largely controlled. But, where an institu- 
tion was once invaded, a number of cases were liable to continue 
for a long time. Two institutions never admitted a patient 
with eye disease until they had received a certificate from him 
that the disease was not contagious; the patients were sent to 
an ophthalmic institution until they were cured of the conta- 
gious affection. These institutions were remarkably free from 
eye diseases. He thought the suggestion of the author of the 
paper regarding competent inspection of all cases of eye dis- 
ease in these institutions a good one, and believed that, if a 
physician were engaged to make a monthly report of the con- 
dition of the eyes of the inmates, at least large epidemics would 
be avoided. In this seemed to be the nucleus of the paper, and 
he knew of nothing more philanthropic which could engage 
attention. 

Dr. D. B. St. John Roosa said that that afternoon, at the 
request of the physician of an asylum, he had examined the 
eyes of 242 inmates and found 67 cases of conjunctivitis. These 
children were under as good care as they could have, thanks to 
the labors of the author of the paper, except that there was not 
isolation. But the authorities of the institutions were not alto- 
gether to be blamed for the existing condition of things. If 
there was any power in the Board of Health to correct such 
matters, it was its urgent duty to do so. Children suffering 
from eye disease were often forced upon the managers of asy- 
lums in a manner that they could scarcely resist. The writer 
had observed with great propriety how very wrong it was to 
send these children back to their already overworked parents or 



PROCEEDINGS OF SOCIETIES. 



[N. Y. Med. Jocr., 



guardians with the hope that they might remedy the matter. 
The remedy was easy. The tax-payers should pay for a hospital 
where patients suffering from contagious ophthalmia could he 
sent and retained until cured and then he returned to the insti- 
tution without danger of spreading the disease. The suhject 
■was one deserving the consideration of political philanthropists, 
and the Board of Health should insist upon the erection of a 
suitable hospital, and it would be found, as it had always been 
found in like cases, that the people of New York were ready to 
give their money for deserving charities. 

Dr. Oakman, of Nyack, said that during the winter the au- 
thorities of the institution at that place, where about one hun- 
dred inmates were admitted, failed to isolate certain cases of 
eye trouble which he advised should be done, they maintaining 
that the disease was- the result of cold. In order to keep the 
inmates warm they were huddled together in an ill-ventilated 
room, and the result was that in the spring there were forty- 
four cases of catarrhal trouble of the eyes, seven of acute granu- 
lar trachoma, and one of purulent ophthalmia. 

Dr. C. R. Agxew said his interest in this matter had begun 
nearly thirty years before, when he saw a great many cases of 
contagious conjunctivitis during a famine in Ireland, and to this 
day that disease was quite common there, having started from 
overcrowding in poor-houses and other public institutions. He 
referred to a school in this city where contagious ophthalmia 
was communicated to eight tenths of the inmates, probably 
largely by the habit of washing together in one trough. They 
were also insufficiently fed, and several slept in the same bed. 
A remarkable change for the better had taken place when they 
were placed in tents and given four hundred quarts of milk a 
day instead of fifteen quarts. Dr. Agnew had great faith in 
the effect of agitation in bringing about a reform of abuses. It 
was not always wise to seek legislation, but in this case he 
thought something should be done by way of legislation. It 
should be required of those who were about to found an insti- 
tution to lodge a certificate showing that they had made proper 
provision for air-space, shelter, food, and medical attendance for 
a certain number of inmates, and it should he made impossible 
for such institutions to receive more persons than the number 
for which they had the lawful accommodations. This was quite 
as possible as to regulate the number of passengers which a ship 
of given measurements should carry. The large majority of 
children in these institutions having chronic conjunctivitis never 
recovered, and they went to make up that large body of drift- 
ing, despairing creatures who infested our towns and cities. 

Mr. Gerry, of the Society for the Prevention of Cruelty to 
Children, explained the manner in which commitments were 
made to these institutions, and said that, with certain excep- 
tions, many of the institutions where the children were sent 
were entirely under the control of persons who had no knowl- 
edge of medicine, or even of nursing, and there was no provi- 
sion in the law which required them even to seek the advice of a 
physician. Unless they were required to submit to the judg- 
ment either of a medical board or of some competent medical 
man, they would always have in their institutions cases of con- 
tagious ophthalmia. He was entirely in accord with the views 
expressed by Dr. Agnew, and thought that something should be 
done by law to provide for an oversight of these institutions by 
medical authorities. He thought, so far as an ophthalmic hos- 
pital was concerned, that the remedy was simple. Let the 
State pay liberally for the care of such cases, and they would 
find proper isolation and treatment. The difficulty with regard 
to the Board of Health was that it was a quasi-politieal body; 
it already had its hands too full of work, it had not the means, 
and, when money was asked for, it was put off with the reply 
that it was always calling for money. One objection to an 



ophthalmic hospital was that the people would feel that as soon 
as a child was sent there its condition was hopeless. 

Mr. Milhau, of the State Board of Charities, explained the 
duties of that board with regard to recommending the estab- 
lishment of institutions organized by private individuals, and 
said that, while such institutions usually started under favora- 
ble conditions, it was only a short time before they began to 
receive children faster than they were able to provide accom- 
modations for them. Then there were institutions which were 
considered absolutely safe, being under the highest medical su- 
pervision, and yet ophthalmia would hreak out. 

The President said it was apparent, from the remarks which 
had been made, that it was almost impossible to keep contagious 
ophthalmia out of institutions. The same was true of every 
other contagious disease ; they all made their appearance at 
times in institutions crowded with inmates. All of these insti- 
tutions were meant to do good, and all did at the same time a 
great deal of harm. Where there were many children there 
were many opportunities for danger. Measles usually was a 
very mild disease, but when it broke out in public institutions 
it became very dangerous, and the same was true of all conta- 
gious diseases ; they were more fatal when present among the in- 
mates of crowded institutions. In an eve hospital a mild case 
of ophthalmia would become a very severe one, and he was not 
sure that much good would come from a hospital devoted spe- 
cially to those cases. The question would finally arise, whether 
public institutions where large numbers of persons were con- 
gregated should be allowed to exist at all. If the children 
gathered in those which at present existed were farmed out it 
would be much better for them ; there would be fewer cases of 
ophthalmia and of blindness. 

Dr. W. F. Mittexdorf said it was difficult to make the pub- 
lic understand two points with regard to contagious ophthal- 
mia: first, its great danger to the eyes, and, second, the length 
of time it required to cure it. He had had much to do with 
asylums, and he thought, with the president, that the crowding 
of children together in institutions was a great source of dan- 
ger. In certain institutions where the inmates lived in cottages 
he had seen little of eye disease. Another point which was too 
often overlooked was the extreme contagiousness of the affec- 
tion. It was because of its great liability to spread that the 
eye institutions in the city did not like to accept cases of con- 
tagious ophthalmia. The suggestion of the president was, it 
seemed to him, the best that c ould be adopted — namely, to put 
as few inmates into one building as possible. 

Dr. Agxew offered the following resolutions, which were 
unanimously adopted : 

Resolved, That it is necessary and expedient that steps be 
taken to prevent the occurrence of communicable eye diseases 
in the schools and asylums of New York and vicinity. 

Resolved, That the Council of the Academy be requested to 
take the matter of the paper into its immediate consideration, 
to obtain the co-operation of the writer of the paper, of the 
Society for the Prevention of Cruelty to Children, of the State 
Board of Charities, of the State Charities Aid Association, and 
others interested in the subject, for the purpose of lessening the 
prevalence of communicable eye disease. 

Dr. Roosa wished to say one word more in favor of an 
ophthalmic hospital. It had been shown in the discussion that 
contagious ophthalmia, although easily spread, was also amena- 
ble to treatment, and, so long as institutions existed where it 
was liable to occur, there should be a hospital where patients 
could he sent for isolation and treatment. Of course, this would 
not be necessary when things were in New York as they were 
in Utopia, and children were all farmed out instead of being 
put into institutions. 



July 18, 1885.] 



PRO CEED TNOS OF SOCIETIES. 



77 



OBSTETRICAL SOCIETY OF PHILADELPHIA. 

Meeting of June 1885. 
( Concluded from page 55.) 

The Surgical Treatment of Infants.— Dr. Willard's paper 
was concluded as follows : 

Congenital hydrocele rarely requires much surgical inter- 
ference beyond an evaporating lotion of chloride of ammonium 
or alcohol, as a few weeks will often close the canal, if hernia 
does not co-exist — a fact which can be determined by non-trans- 
lucency and capability of reduction. Should the connection 
with the peritonaeum fail to close, puncture, with the applica- 
tion of a truss, will usually complete the cure. A hydrocele 
with closed canal is better treated by tapping and injection than 
by seton. The diagnosis between encysted hydrocele of the 
cord, hernia, and undescended testicle is sometimes difficult, but, 
if the surgeon remembers that the former is simply a cyst in 
some unobliterated portion of the peritoneal coat of the cord, 
that its rounded shape can be detected if it is pulled well down 
into the scrotum, that it is usually translucent, that the impulse 
is not so decided as in the case of hernia, that it returns to the 
abdomen only by being pressed upward and not with a slip and 
gurgle, he will rarely be led astray. A hernia may co-exist 
with either of the above-mentioned conditions, but, if non- 
adherent, careful isolation will settle the diagnosis. Should the 
hernia become strangulated or the non-descended testicle be- 
come inflamed and infiltrated, the most careful examination will 
be necessary. In retained testicle, its absence from the scrotum 
will be the first point in arriving at a decision, but even in such 
a condition the organ might be within the abdomen and an en- 
cysted hydrocele present, or the testis might, as has recently 
fallen under my notice, slip into the tissues of the perinasum 
and be exceedingly difficult to discover. In the case just men- 
tioned it sometimes requires numerous manipulations to cause 
the missing organ to return to its place in the pouch. Should 
hernia and retained testicle both exist, a double purpose can be 
gained by drawing the latter down, and pushing the former up 
and then applying a truss. The successful retention of the 
organ within the scrotum is a matter of great difficulty, and 
removal is scarcely justifiable in young persons unless pain or 
inflammation ensues. Extirpation, if required in later youth, 
will probably not interfere with the procreative power of the 
individual, since one gland will supply all requisite material, 
and the affected one is practically useless from atrophy, even if 
it is not devoid of tubular structure. Traction is of little serv- 
ice, as manipulation tends to increase the sensitiveness of the 
organ. 

Simple umbilical and inguinal hernia should receive early 
attention, as, contrary to the rule in adults, a cure can often be 
effected during the first year of life by the persistent use of a 
truss. In young infants I prefer the hard-rubber variety as 
more cleanly. The instrument should be applied during the 
first few weeks of life and continued for one or more years. 
The treatment of strangulated hernia does not differ from that 
in the adult, but, in obstruction of the bowels, intussusception is 
so commonly the cause of the blockade that, unless violent peri- 
tonitis is present, laparotomy, with careful search for the invagi- 
nation, offers the best hope of relief, and, I am glad to say, is 
rapidly growing in favor. 

Meningocele, encephalocele, and spina bifida are complaints 
that will early require the surgeon's attention, or at least his ex- 
pression of opinion and his prognosis. If attached by means of 
a narrow pedicle, constriction with an elastic band is feasible, 
but, unfortunately, this pedicle is but seldom found. Injection 
of iodine, following tapping, is rarely successful, yet is worthy 
of trial in so hopeless a task. In a large hydrorrhachis of the 



lumbar region, lately under my care, which resisted pressure, 
tapping, injection, and constriction, I was slrongly inclined to 
excise the thin sac and attempt a plastic operation by drawing 
in toward the median line two flaps of skin from the lumbar re- 
gion, leaving the vacancies to granulate. Soon after a consulta- 
tion, in which I was dissuaded from my attempt, the tumor rup- 
tured spontaneously and death occurred in two days, although 
frequent tappings had never produced any nervous symptoms. 
I had then never seen a record of such a plan of procedure, but 
only last week I noticed in the "Journal of the American Medi- 
cal Association," vol. iv, No. 17, p. 460, that Mr. Robson had 
performed this operation with successful results in two out of 
four cases. Strict antisepsis was enforced. 

Cephalhmnatomata are usually easily distinguished from en- 
cephalocele or meningocele, and also from the simpler tumor, 
caput succedaneum, the latter being exterior to the periosteum 
and more doughy. The blood in a cephalhaematoma is always 
confined between the pericranium and the bone substance, and 
increases until the second or third day. The hardened ridge 
around the border of the tumor may give the sensation of an 
opening in the bone, but the orifice in meningocele is rarely as 
large as the base of the swelling mentioned. The peculiar crack- 
ling feeling upon pressure at a later period is due to the new 
bone deposits beneath the periosteum. Absorption so generally 
takes place in three or four weeks that aspiration or incision is 
unwise, even though antisepsis be thoroughly practiced, unless 
in exceptional cases when suppuration is certainly present. 

Hare-lip will early require the careful study of the surgeon, 
situated as it is upon the portion of the body that is most re- 
garded from the cosmetic point of view. Its proper relief there- 
fore becomes not only a matter of surgical skill, but of surgico- 
artistic skill. The time for the performance of the operation is 
a point upon which there is a wide diversity of opinion. My 
rule is to relieve the deformity within three or four days if it 
interferes with the proper nursing of the child. Practically I 
must confess, however, that by the end of the operation the 
milk has left the mother's breast, unless there is some other 
baby to maintain the flow. My preference is to wait about 
three months, until a full, vigorous activity of growth and cell 
action is at work, and before the process of dentition has com- 
menced. This period is selected not only tor the reason men- 
tioned, but also because the child can not use its hands so freely 
as at a late period of infancy, thus avoiding risk of injury. In 
one patient a year old, diphtheria appeared on the day following 
operation, and in his convulsions all the pins were twice torn 
entirely from their fastenings aod the fresh wound became im- 
plicated. In spite of such complication, an excellent result was 
obtained by holding the parts in position for days with adhesive 
plaster cut in the form of a triangle, sufficiently large to cover 
at its base the area from in front of the ear to the corner of the 
hyoid bone, with its apex prolonged at the width of the upper 
lip to meet a similarly shaped piece from the opposite side. 
These sections were united by a small elastic ring which main- 
tained a constant pull upon the tissues of the chock and con- 
trolled spasmodic muscular action. In fractious children I have 
now discarded pins and have substituted catgut sutures for the 
mucous surfaces, which, if of small size and tied in three knots, 
will remain in position until union occurs. For the skin edges 
I use carbolized interrupted silk sutures, my reason for stitch- 
ing the surfaces separately being that there is less linear depres- 
sion of the cicatrix, and less constriction of tissues is thereby 
exercised than by pins and the figure-of-eight, while, if each 
set penetrates half-way through the lip antero-posteriorly, the 
sphincter is thoroughly controlled. One of the stitches should 
pierce the coronary arteries. To prevent pouching of the flaps 
or separation of the deeper parts by oozing, horse-hair drainage 



78 



PROCEEDINGS OF SOCIETIES. 



[N. Y. Med. Jouk., 



for a few hoars answers the best purpose. Additional control 

of muscles should be given by adhesive plaster prepared as above 
indicated or by strips, which should not only be applied trans- 
versely, but, in order to prevent strain, should commence upon 
the neck on either side, in front of the sterno-mastoid, near the 
cornu of the hyoid, and run thence just above the angle of the 
mouth across the opposite malar to the front of the ear. If 
these are all put in position while the surgeon pinches the 
-cheeks well together, he will find, upon releasing his grasp, that 
the minimum of tension is exerted upon the stitches. A still 
better plan is to have the nurse regulate this muscular action for 
the first few days by pressure whenever the child cries or eats. 
Only by securing union by the first intention can we hope to 
have a narrow cicatrix ; hence I do not allow the child to suck, 
as is the practice with some surgeons, but prefer spoon-feeding, 
as producing less disturbance. For the same reason, anodynes 
should be employed to control pain and keep the little one for a 
few days in a quiescent state. The child should be in the best 
possible condition physically, as quick union is desirable. To 
avoid the marginal depression so commonly seen, and which is 
inevitable if the simple inverted V-incision is used, I never sac- 
rifice any portion of the paring, but, commencing the incision 
at the apex of the cleft, stop it just before it reaches the border 
of the lip, thus leaving a base of supply to nourish the flap 
which remains on either side. These two flaps, when the parts 
are brought together, project downward and form a fleshy 
prominence : but, if stitched nicely together, will unite and, 
from subsequent absorption during the next year, give a slight 
projection. Even should this be larger than desirable, it is 
far preferable to the ugly notch which can not be corrected, 
since a simple scissor-cut will remove all redundancy and gire 
a nearly normal lip. The same rule in regard to utilization of 
tissue holds good in complicated cases of hare-lip when it be- 
comes necessary to save as much of the alveolus as possible. 
Broken or cut, it can often be worked to advantage in bridging 
the chasm or supporting a fallen nasal septum. 

If deft palate co-exists with hare-lip, an additional necessity 
for early treatment is present, since the closure of the lip will 
tend greatly to lessen the gap in the hard palate. Dentists 
realize more fully than surgeons how slight is the pressure re- 
quired to act upon a tooth or upon the alveolar process, but a 
moment's reflection will convince any practical man that such 
narrowing can be accomplished even if he has never witnessed 
it. In these instances, as in hare-lip and many other deformi- 
ties, neglect is often as much the fault of the physician as of the 
family. An early operation upon the lip, strong pressure upon 
the maxillary bones, followed by the use of a Hainsby's com- 
pressor, will in a few years bring the cleft so close together that 
a single operation will unite the edges. 

These are the considerations which influence me in advising 
that, while the lip should be closed early, the cleft-palate opera- 
tion be deferred until the plan has been tested. Few children 
from five to ten are tractable enough to endure the pain of a 
staphylorrhaphy without ether, which is desirable, and I see no 
particular harm in delaying the procedure until the latter pe- 
riod, save that the unused or malused muscles will require a 
longer period of education after closure. In a recent staphy- 
lorrhaphy upon a boy of sixteen the letters of the alphabet 
could, however, all be correctly pronounced in three weeks ex- 
cept the k and hard-c sounds. If a good velum and uvula can 
be secured by union, the hard palate can be admirably assisted 
by an obturator. Only last week, by preliminary touching and 
the use of cocaine, I was able, in a child of five years, to make 
the parings without pain, and thus avoided anaesthesia until all 
haemorrhage had ceased, ether being employed for stitching 
-only. 



Tongue-tie is a condition that exists more frequently in 
imagination than in reality, yet the operation for its relief 
need be no more than the most trifling nick of the fraenum, 
the finger completing the work. If the organ can be pro- 
truded to the red border of the lip, no operation is neces- 
sary. 

Club-foot is a deformity which is frequently neglected, not 
alone from the apathy of parents, but, as is shown by the cases 
which come under my notice, far more frequently from the in- 
comprehensible advice of the family physician, who has coun- 
seled that "nothing shall be done for the present." Weeks 
slip away into months and months into years, during which 
time one set of muscular fibers and one set of ligaments have 
become elongated, while the opposite ones are atrophied, con- 
densed, and shortened. Bones, too, have become distorted and 
wedge-shaped, and the difficulties have, of course, increased 
fourfold with each advancing year. I have never been able to 
see any reason why delay should be countenanced a single day 
after birth, since manipulation and subsequent fixation can easily 
be accomplished at the first dressing of the child. I know of no 
words sufficiently strong to characterize such neglect of duty as 
is seen in numerous instances. Twice in the last three days 
have I had this matter brought before me by parents who have 
come to the office and who have given as the reason of their 
inaction that the physician had directed them to wait. Even 
before the age for walking, great condensation of tissue will 
take place and increase of deformity will occur from simple 
pressure of clothing, but, as soon as the weight of the body is 
brought to bear upon these misshapen members, the change will 
be rapid. The secret of the cure of club-foot lies not in opera- 
tion, but in careful attention to all the means of relief. At the 
first hour of birth, as I have said, manipulation should be com- 
menced by bringing the foot from the abnormal into a normal 
position, or as near it as possible, and confining it there by 
wood, felt, binder's board, or leather splints rightly adapted. 
At the next visit, leather, gutta-percha, or, preferably, printer's- 
blanket cinctures, should be laced upon the foot and leg, and 
connected by an elastic strap. The two-ply printer's blanket, 
with its rubber face, does not slip, even when applied with only 
moderate tightness, thus being superior to other materials. 
Hook-eyelets are easily inserted by any shoemaker, and the 
lacing need not impede circulation. Manipulation can be prac- 
ticed twenty times a day without taking off the apparatus, while 
removal at night gives opportunities for massage, frictions, etc. 
If co-operation of parents is wanting, plaster of Paris can be 
employed with excellent advantage for fixation, a gain being 
effected with each month's renewal of the dressing. Leather, 
felt, sheet-lead, and silicate of sodium are of use, but do not 
permit removal for manipulation, and are, therefore, inferior to 
the bands already mentioned. These bands, which permit of 
constant elastic traction day and night, are very inexpensive if 
remnants are bought. Their use puts the successful early treat- 
ment of any case of talipes into the hands of the ordinary prac- 
titioner for the first few months of life. In cases which are of 
a severe type, a subsequent operation is usually necessary, but 
the manipulation which has been practiced up to the time for 
tenotomy stretches condensed tissues and increases nutrition so 
that relapse after division of the tendons will not occur, if the 
same measures are continued subsequently. Failure after te- 
notomy is nearly always due to the neglect of manipulation. 
The special form of apparatus is far less important than a strict 
attention to details. The chief advantage of the shoe which I 
employ lies in the fact that it permits manipulation and stretch- 
ing without removal, owing to its flexible sole-shank of upper- 
leathers, which acts_ perfectly as a ball-and-socket joint, the 
force being exerted by an elastic strap operating upon the foot 



July 18, 1885.1 



PROCEEDINGS 



OF SOCIETIES. 



79 



through a catgut cord passing through an eye attached to the 
upright. The eye-bearing arm is ordinarily constructed with 
too little an outward bend. If I can control the patient I rarely 
operate until I have the tissues thoroughly stretched, but if the 
foot can not be placed upon its plantar surface at eight or nine 
months — that is, when the age of walking arrives — tenotomy 
should be delayed no longer, since each step will increase the 
deformity. In operating, I divide every tissue that interferes with 
perfect straightening, whether it is tendinous or fascial. The 
tendon of the posterior tibial is an exceedingly difficult one to 
sever in a fat infant with a poorly developed heel. The punc- 
ture should be made just below the malleolus, and, having 
placed the back of a tenotome toward the artery, division can 
be safely made. Tenotomes, as found in the shops, have too 
long a cutting surface for infantile work, as the sharp edge will 
frequently enlarge the external wound unnecessarily. It is my 
practice to leave the tendo Achillis until the end of the opera- 
tion, in order to gain its fixation power in the leverage required 
for stretching the parts into position, a procedure which is best 
accomplished at the time of operation. The amount of power 
which should be employed in this process is governed by the 
degree of resistance and the caution of the surgeon, special 
care being taken that the force is expended only on the resist- 
ant tissues. In tbe class of cases with which this paper deals— 
namely, those of young infants — it is scarcely possible that tar- 
sectomy could be called for, although an English surgeon has 
thus operated upon a sixteen-months-old babe. I now use the 
gypsum dressing entirely after tenotomy, not only since it is 
less expensive, but chiefly because it holds the foot and heel in 
much better position than is possible by any apparatus, and is 
less liable to produce sloughing, because the pressure is exerted 
over the entire surface. The instances where plaster produces 
a slough are always due to faulty application, mainly caused by 
some indentation produced during the setting process. If the 
bandages are smoothly and rapidly applied (salt having been 
added to the water in which they are immersed), the surgeon 
can, by grasping the knee, hold it steadily in place, while, with 
the palm of his other hand placed against the plantar surface 
of the child's foot, complete rectification can be maintained 
until the plaster hardens without danger of depressing any re- 
gion of the cast. A dossil of curled hair or cotton placed over 
the ball of the great toe and the prominence of the cuboid or 
astragalus, and confined in position by the flannel bandage en- 
veloping the foot, will also assist in averting any harmful press- 
ure. 

I can not too strongly emphasize my appreciation of plaster 
of Paris in the treatment of fractures in infants, giving, as it 
does, a perfectly adaptable material, and yet, when hardened, 
securing an immobility of the injured part that permits free 
handling, provided the articulation both above and below the 
injury is included in the dressing. This is feasible even in frac- 
tures near the hip, since the splint can be made to encircle the 
thorax, and thus prevent the great motion that is always pres- 
ent if only the pelvis is fixed. No risk of injurious swelling 
need be feared if a flannel bandage or a thin layer of cotton is 
first applied to the limb. It is better to saw open a dressing at 
the end of two weeks, and either tighten it or apply a new one. 
Silicate and other rigid dressings harden so slowly that dis- 
placement may occur during the process. The fractures occur- 
ring during birth are often overlooked for several days, and the 
fact that the child moves a particular portion of its body freely 
is not proof that lesion of bone has not occurred. I have seen 
several instances of fractured clavicle in which tho child in- 
dulged in most vigorous movements of the arm. These collar- 
bone breaks are quite common, either from falling out of bod, 
from careless handling, or from the playful jerking of other 



children. The under-waist of an older child, placed in proper 
position over the sound arm and pinned tightly around the 
body so as to include the injured member, often keeps in place 
better in fat babies than a Velpeau bandage, especially if the 
hand is secured with a loop. Borated cotton should be placed 
in the axilla. 

Green-stick fractures are best treated by etherizing the child 
and slowly straightening the bone by hand-pressure. Even 
should complete solution occur, the result will be good. A 
slight curve can be reduced by a splint and bandage. Separa- 
tions of epiphyses are practically fractures, and should be treat- 
ed as such. 

Dislocations do not differ from similar injuries in adults, 
save that they are even more readily replaced by manipulation. 

The resultant deformities of infantile paralysis are numer- 
ous, and are frequently passed over by both physician and pa- 
rents, under the erroneous impression that nothing can be done 
for the relief of these poor weakened members. Recognizing 
that restoration is best accomplished by massage, electricity, 
etc., and particularly by action, it is my rule never to assist a 
muscle if it is capable of permitting locomotion, or unless de- 
formity is being produced by non-support. The following are 
the considerations that determine the necessity for apparatus : 
If a bone is bending, an articular surface becoming distorted, a 
ligament yielding, or muscles becoming atrophied from exces- 
sive stretching, or if, by applying a support, the child can be 
made to walk, then I always order an apparatus which shall not 
take the place of the enfeebled muscles, or put them in splints 
at rest, hut which shall reuder just enough resistance to enable 
them by contraction to accomplish tbe desired purpose. If 
rigid steel is used, they will soon relinquish their attempts at 
assertion of power, and enfeeblement will increase. By ajudi- 
cious adaptation of mechanical appliances, many who are now 
condemned to chairs and beds can be placed upon their feet. 
The advisability of tenotomy will depend upon the benefit to be 
gained by such a procedure. In many cases it will assist great- 
ly in placing limbs in proper position for locomotion, and for 
this reason its mechanical effect should be thoroughly studied. 
My observation leads me to believe that it is employed too sel- 
dom. The excision and shortening of tendons by suturing is 
often of advantage. Any irregularity in the length of limbs 
should be counteracted, lest lateral curvature result. 

N~cevi, if situated upon exposed portions of the body, must 
be cured early in life if rapidly increasing in size, and in the 
majority of cases should be attended to before six months is 
reached. The question of excision, ligature, subcutaneous liga- 
ture, injection, electrolysis, or sun-heat, will depend upon situ- 
ation, size, etc. 

Webbed finger* and supernumerary toes and finger* will yield 
smaller resultant scars if operated on during the first half-year 
of life. 

Wry-neek may follow injury to the spinal accessory nerve 
during labor, or it may be found as a result of some of the ex- 
anthemata. If resistant to local and constitutional remedies, 
myotomy should be performed at the end of a year. 

Spinal caries in young children can be retarded by placing 
the sufferer upon its back between two sand-bags, while pas- 
sive motion is employed to develop muscular power. A jacket 
or cuirass may be added if bone-death is rapid, or if difficulty 
of retention Is experienced. Horizontal extension is rarelj ne- 
cessary. I have occasionally seen lateral curvature in weak 
infants caused by the mother's habit of always holding them in 
one position, the reversal of which custom has, together with 
constitutional remedies, completed a cure. It may also be the 
result of a rhachitic tendency, which will necessitate the appro- 
priate medicinal and hygienic management. Simple posterior 



80 



PROCEEDINGS 



OF SOCIETIES. 



[N. Y. Med. Jode., 



curvature, aud also lordosis, are sometimes found, and should 
be closely watched, as other symptoms of that disease of mal- 
nutrition, rickets, may soon present themselves. Dorsal decu- 
bitus should be maintained until the proper treatment has had 
time to strengthen the child. Rickets, fortunately, is seen upon 
this side of the Atlantic far less frequently than on the eastern 
shores, and, I am thankful to say, is seldom found in Philadel- 
phia even as compared with New York. In fifty thousand 
cases in our hospitals, I find that fewer than fifty are enumer- 
ated under rickets and its results, including knock-knee, bow- 
legs, etc. Its onset is usually within the first six months of 
life, but, unfortunately, many cases are not brought to the 
notice of the surgeon until one or two years have elapsed and 
great deformity has already resulted. When pronounced, the 
most rigid care should be taken to prevent the distortions, from 
which no bone in the body seems exempt. The effects upon 
the female pelvis are most disastrous, as life is thereby endan- 
gered. The recumbent position is the only safe one, and must 
be maintained until the general remedies have time to act, pas- 
sive motion meanwhile taking the place of active. The tibial 
curves are the most common of defects. Very slight bowing is 
sometimes corrected in the growth of the individual, but we 
have no more right to expect that such a result will spontane- 
ously occur 'than that a crooked tree will be blown into the 
upright position by chance winds. The proper means should 
always be used to compel rectification. If the bones are 
spongy, much can be expected from manipulation, pressure, 
and apparatus properly constructed. During the first two 
years of life we may confidently hope to accomplish a good 
result by such means, but in later childhood or adult life, if the 
deflections are great and the bones rigid, and especially if the 
curve is anterior, but little can be gained by these means, and 
osteotomy is the more certain and speedy means of relief. The 
risks of this operation, if done antiseptically, are but very slight, 
as the case, if sealed, becomes one of simple fracture. Plaster 
of Paris, again, gives us the best means of fixation after opera- 
tion, and is very comfortable to the patient. 

I approve of instruments in lateral bow-legs, but, when they 
fail to secure straight limbs in the class of cases above men- 
tioned, I firmly advocate operation. The deformity, if allowed 
to continue, is not only unsightly, but also interferes greatly 
with the locomotive powers. It is not true that a bow-legged 
man is strong. He has, on the contrary, to use his limbs at a 
disadvantage, and, if he is vigorous, it is in spite of his com- 
plaint. 

The question of tracheotomy in young infants, with whom 
our present discussion chiefly deals, is one demanding the 
gravest consideration, whether the dyspnoea originates from 
diphtheria or from true croup. So fatal are the results that 
the mortality in babes below the age of six months is placed by 
some writers as high as ninety-five per cent., and, even taking 
all under two years, we can not expect to save more than from 
ten to fifteen per cent. When we consider, however, that some 
English writers place the mortality of croup without operation 
at ninety per cent., we can not believe that the operation has 
increased the number of deaths. Moreover, when cases are 
taken at the most favorable age and the most favorable condi- 
tions, we can scarcely hope to save more than twenty-five per 
cent, of all patients operated on. I have spoken thus in regard 
to prognosis since some surgeons absolutely condemn the em- 
ployment of tracheotomy for these young patients. I can not 
feel, however, that they are absolutely hopeless, and, if surgery 
can relieve them from the horrid death by suffocation, we should 
not hesitate to give them the aid of science, although a true 
tracheotomy is well-nigh impossible in a young, fat infant, owing 
to the exceeding shortness of the trachea and the great size of 



the thyroid body. It is usually best to do an inferior lar- 
yngotomy (or cvieo-thyro-laryngotomy), making the opening 
through the crico-thyroid membrane, and also through the cri- 
coid if necessary. The risk of haemorrhage is thereby greatly 
diminished, since, while the crico-thyroid arteries may be cut, 
they will be far less troublesome to secure than the vessels 
about the thyroid body or the middle thyroid artery, which 
often lies in front of the trachea. Again, the innominate artery 
may rise high in the neck, or a wound of a vein near the innomi- 
nate may speedily kill the little one, as has happened in a num- 
ber of instances, even when the operator has been experienced. 
The fact that surgeons who have opened the windpipe several 
hundred times look upon this operation as an exceedingly diffi- 
cult one is proof that the utmost care is necessary. The danger 
of wandering from the median line may be partially obviated 
by having the child's head kept perfectly straight and by plac- 
ing the body in exact line with the table. The trachea is some- 
times missed because it has not been thoroughly cleared of every- 
thing before attempting to open it. The puncture should be 
made firmly but guardedly. The size of an infant's trachea will 
surprise one who has never studied it. Although I have given 
large and special study to the anatomy of childhood, both from 
the cadaver and clinically, my first tracheotomy patient died on 
the table before I could insert the tube, my error being in try- 
ing to push the cannula too far back. Unless the urgency is 
great, ether should be given in moderate amount and the opera- 
tion carefully performed. A plunge into the trachea is never 
good surgery ; in infants it would be worse than folly. If a 
circular piece is taken from the crico-thyroid membrane and the 
cricoid, and a pilot used, introduction will be rendered more 
easy. In fat necks, the windpipe may be brought nearer the 
surface by extending the head far backward and by grasping the 
tube on either side and dragging it forward. If fixed thus in 
the median line and retained continuously by an assistant, much 
time will be gained. In a recent case I found it wiser to go 
above a large thyroid body, eveD in a five-year-old child, and 
insert the cannula in the crico-thyroid space. There was after- 
ward a slight burying of the upper edge of the plate, owing to 
its high position, but a strip of sheet-lead obviated this diffi- 
culty. To arrest the venous haamorrhage, just before puncture, 
hot-water sponges answer admirably. After operation, the 
temperature of the room should be kept above 80°. I have 
never opened the larynx to remove a foreign body in a very 
young child, but the universal habit of making the mouth the 
general receptacle of everything makes the introduction of such 
substances exceedingly probable at from one to two years. 

Foreign bodies in the nose, which can not be seized, if not 
removed by sternutatories, should always be sought for with 
the aid of anaesthetics. In the ear the opposite mode holds 
good, since consciousness of pain will often prevent an unskilled 
practitioner from doing great injury to the membrana tympani. 

Joint diseases are best treated by recumbency, with fixation 
or extension. 

Excisions are rarely performed at this early age, and need 
not therefore be discussed. 

I omit strumous and syphilitic diseases and a score of other 
conditions, which might well detain us for hours, since time 
forbids. 

I have thus, gentlemen, hastily touched upon only the more 
frequent of the surgical maladies met with in daily practice 
among infants. Many of the suggestions may be already famil- 
iar to you, but even the brief mention which I have been 
allowed to bestow upon each subject may possibly have served 
to revive in your minds old and forgotten experiences, and thus 
be helpful. You will, at least, see that the field is a wide one, 
and that results are most encouraging. 



July 18, 1886.J 



PROCEEDINGS OF SOCIETIES. 



81 



MEDICAL SOCIETY OF THE COUNTY OF KINGS. 

Meeting of May 19, 1885. 
(Concluded from paye $.9.) 

The Eradication of Syphilis during the First Stage by 
Surgical Means. — Dr. A. H. P. Leuf read a paper on this sub- 
ject. [See page 36.] 

Dr. F. N. Otis, of New York, said that the treatment of 
syphilis was a subject in which he was very much interested, 
and especially as to the point which was announced for discus- 
sion this evening, namely, the eradication by surgical means. 
It was a subject which had interested the surgical world for a 
number of years. Auspitz and Kolliker, of Vienna, he believed, 
were among the first who had claimed success in eradicating 
syphilis by excision of the initial lesion, and reported a large 
number of cases — something less than half a hundred. Others 
had supported the claims of Auspitz by citation of similar suc- 
cess both in this country and abroad, but it was still a mooted 
question whether or not syphilis could be eradicated by excision 
of the initial lesion. It was well understood and had been 
ably expressed by the author of the paper that the invasion of 
syphilis was a gradual process, that the chancre, or initial lesion, 
was the first manifestation, and the second observable manifes- 
tation was the enlargement of the glands in connection with it, 
wherever situated. There were, however, a number of points 
about which mistakes might arise in taking the paper exactly in 
the terms in which it had been read. For instance, in describ- 
ing the chancre as an " ulcer " we had to recognize that the 
chancre was not an ulcer primarily, and was not necessarily an 
ulcer at all, and that the processes of syphilis were not de- 
structive. There was always destruction in chancroid, and this 
was one of the differences between chancre and chancroid. 
Chancre might be acquired without any recognized abrasion or 
breach of the surface. The virus might enter through a rup- 
tured hair follicle. Syphilis might enter through some unob- 
served wound, which healed promptly, no destruction taking 
place, and yet the person would have syphilis just as certainly 
and as severely as if the introduction of the syphilitic principle 
was followed by a typical Hunterian chancre. It was not a pro- 
cess of destruction, but of proliferation, from the very begin- 
ning. Proliferation and aggregation of cells, wherever it com- 
menced, were always its characteristic, whether great or small. 
Now, excision of these cells had been asserted to relieve the 
system of danger of syphilis, they being assumed to be the 
starting-point. It had been demonstrated by histologists beyond 
cavil that this difficulty, instead of being the result of a general 
instantaneous infection, always commenced at a given point, 
and that there was a contagium introduced through a lesion 
of the skin, or mucous membrane, which traversed the system 
slowly through the lymphatic spaces and vessels. Having, then, 
its beginning at a certain point, if it could be determined that 
it had not gone much farther, we might hope for its eradication 
by surgical procedure. But the syphilitic principle, so far as 
we know anything about it, was a cell which possessed the 
power of motion, the power of traversing tissue, and it had 
also the power of generating other cells having equally the 
power of traversing tissues. They were not quiescent, but were 
always moving to a greater or less extent, and in a short time — 
a few days or, perhaps, weeks — they would have traveled along 
the lymphatic vessels and have established local points of pro- 
liferation in neighboring lymphatic glands, thus accumulating, 
so that tho glands became emphatically identical with the chan- 
cre — the initial lesion of syphilis. They contained the samo 
vitiated cell material. Inoculations with the cell material from 
these glands would produce syphilis in a healthy person as cer- 



tainly as with the secretion of the typical chancre. We had, 
then, these cells traversing lymph-spaces and vessels ; and it 
had been maintained, on examination, that they often clung to 
the sides of the lymph channels on their passage through them, 
and in this way often blocked up such channels completely for 
the time being. It was not unusual to see a line of lymphatic 
vessels extending from the initial lesion to the glands in the 
groin distinctly marked by an induration caused by accumula- 
tion of newly generated cells, and, if this be the case, it seemed 
impossible, then, that by excision of the initial lesion alone 
syphilis could be cured. In order to prevent its passage into 
the system, we must eradicate every infected cell, not alone the 
initial lesion, but those which had passed from it into the lymph- 
spaces, vessels, and glands in connection with it. This, of course, 
would necessitate an amount of surgical interference which 
would hardly be justifiable under the circumstances. The facts 
were, so far as he knew anything about them, that as yet no 
case had ever been cured by a simple excision of the initial 
lesion, for the reason that the cells had got beyond the reach of 
the surgeon's knife before he had ascertained the presence of 
this accumulation. He had himself excised perhaps twenty or 
thirty chancres, and carefully kept track of the patients after- 
ward. In some of these cases no positive secondary symptoms 
had followed, but there was always a doubt about such cases 
whether the diagnosis had been correct or not. In these cases 
he had traced the source from whence the disease had been 
acquired ; but he assumed, from their history and appearances, 
that they were genuine cases of syphilis. 

It would not surprise him very much to see some of these cases 
of excision, in which no secondary manifestations had followed, 
develop what was called tertiary lesions ten, fifteen, or twenty 
years hence. We saw so many cases where there had been no 
secondary lesions apparently, and yet the sequela showed that 
the disease did exist. We must recognize this fact, then, that 
there were a great many patients who had the secondary stage 
so slight that it escaped observation, and this was a source of a 
great deal of mistaken diagnosis, and assertions of success in 
treatment which had no real foundation in fact. Among other 
points of special interest alluded to in the paper just read had 
been that of hereditary syphilis. It was a question of great 
interest. He would like to say a few words in regard to this 
subject, and especially to look at it from the point of view 
which was taken by that most distinguished syphilographer, Mr. 
Jonathan Hutchinson, of London. He said that syphilis was 
not an hereditary disease ; and he said distinctly that syphilis 
was no more hereditary than small-pox, and was hereditary in 
the same way as small-pox. It was the disease, and not a dia- 
thesis, that was communicated. This would be found in his 
article on syphilis, etc., published in London, in 1884, in a little 
work entitled " The Pedigree of Disease." This position was 
certainly a very startling one in view of the doctrine heretofore 
held by the profession at large. For his own part the speaker 
was quite willing to accept it. In point of fact, the views which 
he had held and advocated, first in his "Physiology and Pa- 
thology of Syphilis," published in 1880, made such a conclusion 
the logical sequence of the position assumed in that work. 
Afterward, in his work on " Genito-urinary Diseases and Syphi- 
lis," published in 1883, there occurred a chapter on the syphilis 
of infants and the so-called hereditary syphilis in which the 
question was considered from tho standpoint of a gradual 
material syphilitic infection through a diseased cell or germ 
as opposed to the mysterious instantaneous doctrine held by 
most authorities, and the only logical deductions from these 
promises fully warranted the statement (first made by Mr. 
Hutchinson in 1882) that syphilis was never the result of he- 
reditary transmission. It seemed to him that there were 



82 



MISCELLANY. 



[N. Y. Mkd. Jour., 



many things that hitherto had not been understood which 
pointed to the truth of this teaching. For instance, syphilis 
was said to be communicated by the male parent to the 
child by heredity. This was accepted by almost all authori- 
ties. Now, it was likewise asserted by all authorities that 
the physiological secretions — sweat, milk, saliva, mucus, urine, 
tears, and semen — did not contain the contagium. The latter 
was particularly mentioned. They all mentioned it. If we 
referred to any of the transatlantic authorities, we should find 
this statement confirmed. Our own authorities — Bumsted, 
Taylor, Van Buren, and Keyes — all stated distinctly that it was 
well ascertained and accepted that the semen did not contain the 
contagium of syphilis. If that was the case, it would be inter- 
esting to know how they would answer the question as to how 
the male had access to the ovum — how the male could com- 
municate syphilis to an embryo or to an unborn child. This 
was a question which it might be well to think of. The facts 
probably could be shown to be that whenever the ovum, or 
foetus, or child had syphilis — syphilis that had been acquired in 
utero — the mother had first been infected; that, if due to the 
male parent, he must necessarily have given the disease first to 
the mother, and she in turn to the child. Now, there was a 
curious fact spoken of by Diday. He said it was a well-known 
law that no woman could communicate to her infant a syphilis 
which she had acquired not to exceed two months previously 
to the birth of the child. So certain was Diday's belief in this 
law that he said he was willing to give to a healthy woman to 
nurse a child of a woman who bad acquired her disease not 
more than two months previous to her delivery. Now, there 
were two months during which it was accepted as a clinical 
fact the child is safe. If the mother acquired her initial lesion 
only two months previous to the birth of the child, that child 
could not acquire syphilis in utero. The question at once arose, 
Why was this ? It was because the syphilitic poison was not 
yet in the blood of the mother, that it required two months 
at least for it to get into the blood of the mother, and then only 
could she communicate it to the embryo or to the child. This 
also proved what had been stated in the paper of the evening 
in regard to the gradual infection of syphilis. Before this was 
understood, this rule of Diday could hardly be comprehended. 

Dr. Baetlett, of Flatbush, remarked that all physicians 
having a large experience with the criminal classes knew but 
too well the moral, intellectual, and physical misery and degra- 
dation entailed by syphilis. In view of this, he thought that, 
in certain cases, both for the good of the criminal and the pro- 
tection of society, a more radical and serious surgical operation 
would be justifiable than the one proposed. The principle of 
heredity was so strong that society had the right to protect 
itself in these cases by preventing the possibility of procreation. 

Dr. George R. Fowler took exception to the statement 
made by the essayist that tertiary symptoms of syphilis almost 
always occurred. The speaker was of the opinion that syphil- 
ographers of the present day maintained that tertiary symptoms, 
and particularly those of a severe type, were rather rarely met 
with. He further believed that it was a growing impression 
that syphilis in its protean form was, so to speak, " running out." 
The syphilis of to-day was not the syphilis of one hundred years 
ago, and many of the cases which were supposed to have escaped 
syphilis because of excision of the initial lesion were cases 
in which possibly no manifestation of the disease would have 
occurred at all. He alluded to the fact that in Auspitz's experi- 
ments, in those cases in which the characteristic sclerosis reap- 
peared at the point where the chancre had been excised, con- 
stitutional syphilis occurred irrespective of the existence or 
non-existence of indurated glands prior to the excision. This 
must make it appear that there was a stage of the disease dur- 



ing which the condition of the glands, so far as we were able 
to determine it, had very little, if anything, to do with the de- 
velopment of the sequelae, if the subsequent stages in their de- 
velopment might be so denominated. Dr. Leuf had said it was 
well proved, although not generally known, that self-inocula- 
tion was possible prior to systemic infection ; and that brought 
us at once to the important point in the discussion of the ques- 
tion of the excision of the initial chancre together with the in- 
durated glands. The cases cited by Auspitz, in which con-ti- 
tutional syphilis occurred in spite of the fact that no induration 
of the inguinal glands took place prior to such development, 
suggested the possibility of channels of infection other than 
these lymphatics. He recalled a case in which a surgeon re- 
moved a tumor of the testicle, and, while excising some indu- 
rated glands in the groin, accidentally pricked his thumb. In 
due course of. time a syphilitic chancre made its appearance at 
the site of the little wound, and this in its turn was followed 
by constitutional syphilis. Although the patient had denied 
venereal disease when admitted to the hospital, yet he acknowl- 
edged to the surgeon subsequently that ten years before he had 
had a sore upon his penis, for which he did not seek advice, 
and that the indurated glands in the groin had existed since that 
time. No other manifestation of the disease had ever occurred. 
If it could be supposed that this patient had kept the virus stored 
up in these indurated glands for ten years, then we could see our 
way clear, in a certain proportion of cases, to a hope of benefit 
to be derived from excising such glands as early as practicable. 

Dr. Lecf, in concluding the debate, saw, in reference to the 
remarks of Dr. Otis, that that gentlemen had entirely misun- 
derstood him. He had expressly stated that the primary lesion 
was not an ulcer. With reference to the implication of the 
lymphatic vessels, if they were at all involved, perhaps whether 
they appeared to be involved or not, it might be most proper 
to excise them. As to the justifiability of the operation, he 
would say, if it was justifiable to extirpate a whole breast, to dis- 
sect away all the fat and superficial fascia down to the pectoralis 
major, and clean out the whole axilla because there was a little 
nodule in the breast, it certainly ought to be justifiable to re- 
move from the end of the penis a small sore, and even a few 
glands and lymphatic vessels running therefrom. With refer- 
ence to Dr. Fowler's observation that syphilis was not so bad 
as it was one hundred years ago and was "running out," the 
speaker thought if that were so the operation might be justi- 
fiable on the ground that by its means it might be made to " run 
out" so much the quicker, and he thought it was not wise to 
excise the lesion without scooping out the glands also. If these 
lymphatic vessels and everything in their immediate vicinity 
were excised, "cleaned out," he thought an additional safe- 
guard would be effected, and he did not think the operation 
very dangerous. A surgeon of the enthusiasm of Dr. Fowler 
ought not to see any particular danger in it. Dr. Fowler had 
also referred to the possibility of there being some other chan- 
nel of absorption on account of the non-infection of the glands, 
apparently. There seemed to be no other channel except the 
blood, and the speaker thought that idea had been refuted in 
the paper. If it was not through the blood, it must be through 
the lymphatic or other channels that he knew not of. 



Ultstjellana . 



The Ninth International Medical Congress. — Speaking of the 
action of the enlarged committee, the " Boston Medical and Surgical 
Journal " says : 



July 18, 1885.] 



MISCELLANY. 



83 



" The committee did the work expected of it, and with less malice 
than would have been possible, but with sufficient thoroughness, we 
fear, to put an end to the prospects of a successful and creditable in- 
ternational congress, and adjourned to meet in St. Louis on the first 
Monday in May, 1886. The rules were amended so as to confine mem- 
bership to the constituency of the American Medical Association. The 
American members, it is decreed, shall consist of delegates from the 
American Medical Association, and from medical societies in affiliation 
with it, each of these societies being entitled to one delegate for every 
ten members. The number of sections was reduced from nineteen to 
sixteen, and the presidents of sections are no longer ex-officio members 
of the General Committee. 

" Dr. H. I. Bowditch, of Boston, was dropped from the list of vice- 
presidents, Dr. A. Jacobi from the presidency of the Section of Diseases 
of Children, Dr. Lefferts from that of Laryngology, Dr. H. P. Bowditch 
from that of Medical Education, and Dr. H. D. Noyes from that of 
Ophthalmology. Numerous changes and additions were made in the 
vice-presidents and members of council of the different sections. Those 
honors are issued as plentifully as fiat money after a coup d'etaf, and 
the various geographical divisions of the country are impartially be- 
sprinkled with them. A publication of the full list would require 
much space ; and, as this is already the second long list made public 
within a few months, as the refusal by many prominent men to serve 
as officers under existing conditions makes certain the appearance of 
other revised lists, which may eventually end in no list at all, we con- 
tent ourselves with referring our readers to our news columns for the 
present organization of the Congress and for changes in the presidents 
and vice-presidents of sections. In the same columns will also be 
found a report of the action of prominent physicians in Philadelphia 
and Boston connected with the organization of the Congress. These 
refusals to accept office in the present organization will doubtless be fol- 
lowed by others. 

" These gentlemen proposed to aid and participate in the discussion 
of questions of medical science, not of medical ethics, medical politics, 
or of square miles of territory. There will, however, be more offices, 
although less congress, for those who prefer such discussions and such 
distinctions to a harmonious gathering of scientific men searching for 
truth ; and we hope somebody may be happy, if it be only for a short 
time." 

In a very temperate article on the same subject, the " Maryland 
Medical Journal " says : 

" Looking at the work of the General Committee, it seems to us that 
it has endeavored to make but few changes, and that it has performed 
the disagreeable duty assigned to it by the association in an extremely 
mild way. It has managed to make a few alterations in the chairman- 
ship of the sections and to add a few college professors, formerly over- 
looked by the original committee, to the sections. It has, however, 
performed, in our judgment, the most stupendous work of supereroga- 
tion ever exacted from a body of intelligent men. We are totally un- 
able to see how the fortunes of the Congress have been a tithe benefited 
by the changes made. On the contrary, it has suffered immensely in 
the eyes of all unbiased thinkers by this unnecessary controversy 
about representation on sections and ' New Code ' principles. As the 
Congress now stands organized, we much doubt its ability to attract 
that attention as a scientific body it was entitled to. How can those 
men interested in pure science feel that same interest in the for- 
tunes of an organization handicapped with contentions for offices and 
ethics and weighted down with that ponderous body, the American 
Medical Association ? It is truly an unfortunate circumstance which 
has happened to impair the usefulness of the International Medical Con- 
gress. While we still trust that wise counsels will prevail, that bitter 
differences will subside, that men will consent to work together in har- 
mony for the success of the Congress, it seems quite clear to us that 
the Ninth International Medical Congress can not take the position it 
would have assumed under its first organization. It is an apt saying, 
Two wrongs can never make a right. The mistakes of the first com- 
mittee — if such were made — have not been corrected by the present 
committee. We fail to see how the few changes which have been made 
in the officers of the Congress can do otherwise than impair its useful- 



ness and drag it down to the level of a promiscuous social and semi- 
scientific gathering. It is a sad commentary upon the status of the 
profession in America that a petty squabble for a few positions should 
have marred what had promised to be one of the most noted scientific 
meetings ever held on American soil. What view our transatlantic 
brethren will take of this status of the Congress it is not difficult to 
surmise. We presume that the American Medical Association will en- 
joy the banquet it has prepared to its own eminent satisfaction, while 
the rest of the profession will look on from a distance. We can not 
but deplore the present outlook, and profoundly trust that the final 
result will be more satisfactory than present indications would seem to 
warrant." 

The "Peoria Medical Monthly" says: 

"We believe the whole trouble has arisen from personal grounds 
on the part of a few who were overlooked when the places of honor 
were distributed. It was purely a fight of the 'outs' against the 'ins ' 
and, now that the ' outs ' have gained the field, the existence of the Con- 
gress is jeopardized. 

" It can not be claimed that the American Medical Association at 
New Orleans represented the medical profession of this country, or if 
the claim be made it is a laughable one. And it can not be denied 
that the American Medical Association, with every similar body in the 
country, is more or less ruled by coteries and cliques. 

" The situation is a deplorable one for the good name of the medi- 
cal profession in America. Our European brethren will hesitate to 
attend the Congress at Washington in very large numbers, for they will 
have reason to fear that the factional feeling and jealousies of certain 
members of the ' rule or ruin ' party in the American Medical Associa- 
tion will carry their fight into the Congress itself. 

" What is to be done to remedy the trouble and preserve the good 
name of the profession of America ? We do not know ; perhaps the 
best thing that could be done would be to notify the Executive Com- 
mittee of the last Congress that, owing to the war raging in the United 
States, the next Congress should be held elsewhere, either in Europe or 
Canada." 

Science and Modern Discovery. — The present occupant of Sir Isaac 
Newton's professorial chair at Cambridge University, Professor G. G. 
Stokes, F. R. S., who is also secretary of the Royal Society of London, 
delivered a remarkable address at the annual meeting of the Victoria 
Institute, in London, toward the end of June. Professor Stokes gave 
an important account of the progress of physical science during the past 
quarter of a century, and, reviewing the results, specially noted that as 
scientific truth developed, so had men to give up the idea that there was 
any opposition between the Book of Nature and the Book of Revela- 
tion. He said that for the last twenty years or so one of the most strik- 
ing advances in science had been made in the application of the spec- 
troscope, and in the information obtained with regard to the constitu- 
tion of the heavenly bodies. The discovery that there were in these 
particular chemical elements which were also present in our earth ex- 
alted our idea of the universality of the laws of Nature, and there was 
nothing in that contrary to what he had learned in Revelation, unless 
we were to say, as the heathen did, that the God of the Hebrews was the 
God of the hills and not of the valleys. Entering with some particu- 
larity into the composition of the sun, he said this gave an idea of an 
enormous temperature, since iron existed there in a state of vapor. 
This was utterly inconsistent with the possibility of the existence there 
of living beings at all approaching in character to those we had here. 
Were we, then, to regard this as a waste of materials ? Might we not 
rather argue that as in animals we ascended by greater specialization so 
we could consider the differentiation of office in different members of 
the solar system as marks of superiority, and could regard the sun as 
performing most important functions for that system ? In fact, all 
life on our earth was ultimately derived from the radiation of solar heat. 
Referring to the doctrines of conservation of energy and of dissipation 
of energy, he pointed out at some length how the sun, so far as we could 
see, was not calculated for an eternal duration in the same state and 
performing the same functions as now. We must regard the universe 
on a grand scale, and then there was progress. If we contemplated 
nothing but periodicity, perhaps we might rest content and think things 



84 



MISCELLANY. 



[N. Y. Med. Joub* 



would go on for ever as at present ; but, looking on the state of the 
universe on a grand scale as one of progress, this idea obliged us to re- 
fer to a first cause. He concluded with recommending that the Annual 
Report of the society, read by Captain Frank Petrie, the honorary sec- 
retary, be adopted. It showed that the number of home, American, 
and colonial members had increased to upward of eleven hundred, and 
that the Institute's object, in which scientific men whether in its ranks 
or not aided, was to promote scientific inquiry, and especially in cases 
where questions of science were held by those who advanced them to 
be subversive of religion. All its members and one-guinea associates 
received its Transactions free, and twelve of its papers were now pub- 
lished in a People's Edition, which was to be had in many of the colo- 
nies and in America. The address was delivered by Dr. J. Leslie Por- 
ter, president of Queen's College, Belfast, the subject being " Egypt : 
Historical and Geographical," a country with which he had been thirty 
years intimately acquainted. Having referred to the antiquity of Egyp- 
tian records, which in so many instances bore on the history of other 
ancient countries, he proceeded to describe the various changes through 
which that country had passed since its first colonization ; and, touch- 
ing on its physical geography, concluded by giving the main results of 
recent exploration. He said : " Were the Nile, by some convulsion of 
Nature, or by some gigantic work of engineering skill — neither of which 
is impossible — turned out of its present channel away up to Khartoum, 
or any other point above Wady Haifa, Egypt would speedily become a 
desert." No tributary enters the Nile below Berber — that is to say, for 
the last thousand miles of its course. " The arable land of Egypt is 
about equal in extent to Yorkshire." The White Nile, issuing from 
Lakes Albert and Victoria Nyanza, is broad and deep, never rises above 
a few feet, and supplies the permanent source of the river of Egypt. 
" The other tributaries produce the inundation." Of these the Atbara, 
from the mountains of Abyssinia, is the most fertilizing, as it brings 
down with it a quantity of soil. The deposit of this soil is slowly rais- 
ing the bed of the river as well as extending on each side ; for exam- 
ple, on the plain of Thebes the soil formed by deposits has in thirty-five 
hundred years encroached upon the desert a third of a mile, " while the 
ruins of Hierapolis in the Delta, which once stood above reach of the 
inundation, are now buried in a mud deposit to a depth of nearly seven 
feet." In conclusion, he referred to Egypt and its present condition, 
saying: "The commerce from the upper tributaries of the Nile, and 
from the wide region of the Soudan, forms an essential factor in the 
prosperity and progress of Egypt." 

How to avoid Night Calls. — A story is going the rounds (who 
started it we do not know) at the expense of the young physician who 
is always so busy that he doesn't know what to do. " I have got more 
business than I can attend to," boasted he to an old practitioner who 
knew he lied. " I had to get out of bed five times last night." " Why 
don't you buy some insect powder ? " quietly asked the old doctor. — 
Medical Age. 

Prizes for Electrical Appliances. — We learn from the " Chicago 
Tribune " that the Mcintosh Company, of that city, received the first 
medal for fine displays of electrical goods at the New Orleans Expo- 
sition. 



THERAPEUTICAL NOTES. 

Glycerin as a Preventive of Trichiniasis. — Merkel (" Dtsch. Arch, 
f. klin. Med." ; " Ctrlbl. f. kliu. Med.") relates the case of a man who 
ate a portion, as long as one's finger, of a sausage in which living 
trichinae .abounded. Twenty hours after the ingestion of the sausage 
he was purged thoroughly with senna, and several specimens of the 
trichina, non-encapsulated, together with fragments of the parasite, 
were found in the dejecta. The next day he was given a tablespoonful 
of pure glycerin every hour until fifteen doses had been taken. This 
caused no unpleasant symptoms beyond thirst and a feeling of dryness 
in the mouth, and the man escaped trichiniasis, while others who had 
eaten of the sausage were attacked with the disease. 

Naphthol. — Mr. W. J. Rigney, of New York, an analytical chemist, 
writes to us as follows : " The extraordinary power of naphthol as an 
antiseptic and disinfecting agent has been known for a long time, but 



its disagreeable smell and the difficulty of preparing it in a pure state, 
with the occasional toxical action of the crude naphthol, have been a 
bar to its use as a remedial and antiseptic agent. Justus Wolff, a 
chemist interested in coal-tar products, has recently succeeded in pro- 
ducing it in a pure and odorless state, in well-defined crystals, and 
states that its antiseptic action is much greater than that of carbolic 
acid. Recent research has demonstrated that the toxic effects of crude 
naphthol are due to the impurities it contains. Dr. Shoemaker, of 
Philadelphia, as he stated in a paper read before the Philadelphia 
County Medical Society, has conclusively proved the non-poisonous 
character of the purified or odorless naphthol by taking large doses in- 
ternally. It has no corrosive action on the skin, and will not injure 
textile fabrics. As a remedial agent, it acts with greater efficiency than 
carbolic acid, over which it has many advantages, and the fact of its 
being absolutely odorless will make it a desirable substitute. It is ex- 
pected that it will shortly be produced on a manufacturing scale as a 
substitute for carbolic acid." 

A Gargle for Chronic Pharyngitis. — The " Union medicale " attri- 
butes the following formula to Bamberger : 

Chloride of ammonium 75 grains ; 

Honey of roses 760 " 

Water 12$ ounces. 

To be used several times a day, together with mustard foot-baths,, 
the use of tobacco being prohibited. 

Belladonna in the Treatment of Intestinal Obstruction. — Dr. T. J. 

Hudson (" Med. Times and Gaz.") thinks that in these cases the best 
way to use belladonna is to apply the extract to the abdomen with very 
hot poultices, and to give one or two grains of the extract as a supposi- 
tory every hour, or inject xhs °f a grain of atropine every two hours 
until slight dilatation of the pupil is maintained. If the pain continues, 
and is serious, an injection of -/•„- of a grain of atropine, with J of a 
grain of morphine, is the best, as it combats depression and nausea. 
Morphine alone often increases the obstruction by causing or increasing 
nausea and, in the early stage of intussusception, preventing the bowel 
from righting itself by its own muscular power. He adds the caution 
that lime-water should not be given, as it decomposes atropine. 

The Treatment of Seasickness. — " In our own person," says a re- 
viewer in the " American Practitioner," " the bromide availed not, nor 
would the Seidlitz stay down, but the Mellin's food was acceptable and 
useful, while a good article of kumys was most grateful to the palate 
and did much to allay nausea." 

Hydrobromate of Quinine and Valerianate of Caffeine in the 
Treatment of Malarial Poisoning. — Cerededo ("Gazz. degli Ospit."; 
" Rev. med.") concludes from numerous experiments that the hydro- 
bromate of quinine is preferable to the sulphate for the following rea- 
sons : 1. Its activity is greater in moderate doses. 2. It acts as a nerv- 
ous sedative. 3. It stops vomiting, a matter of special importance in 
certain countries. 4. It readily brings about a favorable change in the 
type of the fever. 5. Its bitterness is less marked. 6. It does not 
irritate the intestinal mucous membrane, and produces neither consti- 
pation nor diarrhoea. 7. It allows of the avoidance of too frequent 
subcutaneous injections. 8. It diminishes the probability of relapse. 
9. When once the paroxysm has come on, if it can not reduce its inten- 
sity and duration, it should be administered in capsules, combined with 
valerianate of caffeine. 10. Given in that way half an hour before the 
paroxysm, it is capable of arresting the latter. 11. By combining the 
two salts (fifteen grains of the hydrobromate and seven or eight grains 
of the valerianate), we may check certain quotidian forms which are' 
rebellious to much larger doses of the sulphate. 12. The action of this 
combination of the two drugs, given in comparatively small doses, is 
more powerful than that of any other salt of quinine in much larger 
doses. 

The Treatment of Epistaxis. — Introduce into the nostril, to a con- 
siderable distance upward, a piece of fine sponge, cut to the size and 
shape necessary to enable it to enter without difficulty, previously 
soaked in lemon juice or vinegar and water. The patient is to be kept 
lying on the face for a length of time, with the sponge in place. This, 
says " Lyon medical," is the procedure employed by M. Siredey for con- 
trolling epistaxis in typhoid-fever patients. 



THE NEW YORK MEDICAL JOURNAL, July 25, 1885. 



lectures an b |l b b r t s s * s . 



LECTURES OJST 
ELECTRICITY IN MEDICINE, 

DELIVERED AT THE MEDICAL DEPARTMENT OF THE UNI- 
VERSITY OF VERMONT, BURLINGTON, 

By AMBROSE L. RANNEY, M. D., New York. 

( Continued from page 63.) 

Part HI. 
Electro-therapeutics. 

We have now discussed the essential points pertaining 
to electro-physics and electro-diagnosis, and there remains 
now for us to consider the uses of electricity in the treat- 
ment of diseased conditions of various organs and tissues. 

Before we pass to details of the practical part it may 
be well for us to review in a general way some of the laws 
which should govern us in applying electric currents to the 
different tissues, and the objects to be attained by the em- 
ployment of faradaism, galvanism, and static electricity. 

GENERAL ELECTRO-THERAPEUTICS. 

The rapidity and completeness of reported cures by the 
use of electric currents upon living tissues during the last 
quarter of a century leave no room for doubt that this agent 
is particularly valuable in the treatment of paralysis, neural- 
gia, spasmodic diseases, disturbances in the sensibility of 
the skin, and many disordered states of the brain, spinal 
cord, and peripheral nerves themselves. We have undis- 
puted facts which prove also that blood may be coagulated 
with safety within some aneurysmal sacs by the galvanic 
current, that the life of the ovum may be destroyed in extra- 
uterine pregnancy, that animal tissues may be disintegrat- 
ed by chemical changes induced within them by this agent, 
and that neoplasms may be removed without haemorrhage 
by the cautery loop. 

Our present ignorance of the molecular and nutritive 
changes in tissues (as the cause or result of disease) renders 
it impossible to do more than speculate upon the theory of 
the therapeutical action of electricity in many cases ; but, 
on the other hand, our empirical knowledge of these effects 
is none the less valuable because we are unable to explain 
them. The same criticisms would otherwise hold good in 
reference to almost all of the drugs employed in medicine. 
None of us know exactly how they produce their specific 
effects. 

Concerning speculation upon electrical effects on living 
tissues, Erb remarks as follows : " What appears more nat- 
ural than that neuralgia and spasms could be relieved by 
the sedative action of the anode, with production of anelec- 
trotonus, and that anaesthesia and paralysis could be cured 
by the exciting action of the cathode, with production of 
catelectrotonus ? But, apart from the fact that we are not 
certain that an increase of irritability really occurs in one 
group of cases and a diminution in the other, it must be 
remembered that electrotonic action disappears very rapidly 



after the cessation of the current, while the curative effects 
of the current are more or less permanent." 

Now, we may summarize the general principles which 
regulate the use of electric currents as follows: 

1. They may exert, under certain circumstances, a stimu- 
lating or irritating effect. This is, perhaps, the basis of the 
most varied applications of electricity to disease. 

2. They may exert, when properly applied, a sedative 
action on nerves or nerve-centers. 

3. They may be made to exert a catalytic action upon 
neoplasms, enlarged glands, etc. 

4. They are capable of causing electrolysis. This action 
is one which has lately come into prominence. 

5. They create heat under certain conditions. The 
galvano-cautery is to-day assuming a very prominent place 
in some of the departments of surgery. 

Let us now discuss each of these special actions sepa- 
rately, noting the general points of interest pertaining to 
each which will aid us in properly treating our patients. 
Electrolysis and the galvano-cautery have been treated of in 
previous lectures. 

Stimulating or Irritating Effect of Electricity. — 
This is indicated in many diseased conditions. Among 
these the following may be prominently meutioned : 

Some of the various forms of cerebral and spinal dis- 
eases. 

Depressed irritability of some special nerve-trunks. 

Abnormal resistance to conduction of electric currents, 
exhibited by the motor or sensory nerve-filaments of some 
part. 

As a counter-irritant to some pathological conditions. 
Trophic disturbances of special regions (skin, nails, hair, 
etc.). 

Vaso-motor depression. 
Atrophic changes in muscles. 

As a means of indirectly affecting the nerve-centers 
through the sensory nerves, thus influencing respiration, cir- 
culation, phonation, vaso-motor paths, peripheral organs, 
the muscles, etc. 

The methods of application which are best adapted to 
accomplish irritating or stimulating effects are differently 
stated by authors. Personally, I do not confine myself ex- 
clusively to faradaism or galvanism. 

The faradaic current is more commonly employed for 
this purpose than the galvanic. The electrodes should be 
selected, as to their size and shape, in accordance w ith the 
parts to be acted upon ',„they should be well moistened with 
salt water, and kept closely in contact with the skin. The 
wire-brush is the best electrode to stimulate the nerves or 
other tissues of the skin. It should be used dry. 1 prefer 
the secondary faradaic current to that of the primary coil 
for stimulating effects. 

If galvanism is employed as a stimulant, Remak's plan, 
of moving the well-moistened cathode rapidly over the 
nerve-trunk or muscle to be stimulated, with a current suffi- 
ciently strong to cause strong wave-like contractions, is a 
good one. Another method, termed by this author " ter- 
minal labile stimulation," consists in stroking the tendinous 



86 



RANNEY: LECTURES ON ELECTRICITY IN MEDICINE. 



[N. Y. Med. Jock., 



end of a muscle with the cathode so as to affect the entire 
length of the muscle. In both of these methods the anode 
is kept stationary upon some indifferent or neutral point — 
the center of the sternum by preference, or the nape of the 
neck. 

One of the most vigorous methods of stimulation con- 
sists in rapidly changing the polarity by means of a com- 
mutator, when the galvanic battery is employed. 

The Combined Current. — Another method which I em- 
ploy (not generally mentioned in text-books) consists in 
connecting a galvanic battery, by means of a rheophore, with 
a faradaic instrument, thus bringing both a constant and in- 
duced current to bear upon the tissues at once. The rheo- 
phore which connects the batteries joins the positive bind- 
ing-post of the galvanic instrument with the secondary coil 
of the faradaic ; the two rheophores connected with the elec- 
trodes run from the negative binding-post of the galvanic 
and from the secondary coil of the faradaic instrument. The 
two instruments (faradaic and galvanic) are thrown into 
action simultaneously, and the strength of the current em- 
ployed is graduated by the number of cells used in the gal- 
vanic battery and by the extent of the overlap of the sec- 
ondary coil of the faradaic instrument. I have obtained 
some remarkable results by the stimulation thus produced 
in various forms of trophic disturbances of the skin and 
muscles. 

The stimulation of nerve-fibers (when obstacles exist to 
their conduction) should be performed peripherally from 
the site of the lesion in sensory nerves, and as centrally as 
possible in motor nerves (Erb). Degenerated and atrophied 
nerves and muscles require a direct effect of the currents 
employed. For these reasons, the site of stimulating elec- 
trical applications depends upon the situation and character 
of the lesion and the object to be attained. 

Modifying Effects of Electric Currents. — The irri- 
tability of nerves and muscles may be influenced by electric 
currents. 

In certain diseased conditions we may expect a favorable 
result from such an action. Thus, for example, in some 
types of paralysis, in anaesthesia, in certain vaso-motor dis- 
turbances, and in depressed states of cerebral and spinal 
activity, the irritability of nerves or of muscular fibers is 
diminished ; hence we resort to the so-called " catelectro- 
tonic action " of electricity as a means of stimulating and 
restoring the normal irritability of the tissues affected. 

It is now generally accepted as proved that feeble faradaic 
currents will accomplish this end. Galvanic currents, when 
applied for this purpose, give more positive results, however, 
than faradaic. 

In order to increase irritability by galvanism, the nega- 
tive electrode should be applied in a stabile manner (i. e., 
without being moved) to the part upon which this effect 
is to be produced ; and the strength and duration of the 
current should be steadily increased. When the muscles 
or motor nerves have been exhausted by over-exertion, ex- 
cessive fatigue, etc., this action (termed by Heidenhain 
the " refreshing action " of galvanism) is particularly in- 
dicated. 

Those conditions in which the normal irritability of 



nerves or muscles is intensified demand the so-called " ane- 
lectrotonic action " of electricity. These conditions com- 
prise all irritative states of the sensory, motor, and vaso- 
motor tracts within or without the brain and spinal cord ; 
hence we employ this action in neuralgias, spasmodic affec- 
tions, hypenesthesia of any of the cerebro-spinal nerves, 
headache, excitation of any of the special senses, cerebral 
and spinal irritation, etc. 

In order to decrease the irritability of nerves or muscles, 
we may employ very powerful faradaic currents. We may 
also begin by employing a feeble faradaic current and grad- 
ually increasing its strength to the highest point of endur- 
ance ; then maintaining it at this point for some time ; and 
subsequently reducing it gradually to the feeblest current 
perceptible to the patient. This method is known as the 
" increasing induction method." Electrodes well-moistened 
and of large size should be employed and kept immovable 
upon the same points during the application. It is often 
advisable to repeat this procedure several times at one sit- 
ting (Erb). 

When the galvanic current is employed for the purpose 
of decreasing irritability, the positive pole is made fast at 
the point to be influenced. The current is increased in 
strength and maintained at its maximum for some time, after 
which it should be decreased gradually until it can not be 
perceived by the patient. The gradual decrease of the cur- 
rent-strength prevents the marked temporary increase of 
irritability which is liable to follow this method when this 
step is omitted. 

Static electricity exerts in many cases an immediate bene- 
ficial effect upon neuralgic pains (especially upon sciatica) 
and upon the various spasmodic affections, as, for example, 
chorea, paralysis agitans, tremor, contracture, etc. These 
effects are obtained, in some cases, when galvanism and 
faradaism have proved of no benefit. I should never regard 
a case as incapable of benefit by electric treatment until 
static electricity, in the form of insulation, the electric wind, 
or the spark, had been thoroughly tested. I have had bet- 
ter results with this form of current in tremor than with 
galvanism or faradaism. 

Some forms of pain (as, for example, the pains of ataxia, 
sciatica, trigeminal neuralgia, muscular rheumatism, etc.) 
are oftentimes relieved by a few applications of static elec- 
tricity. My experience with this agent has convinced me 
that its effects are often satisfactory in cases where pain is a 
prominent symptom, when galvanism has been tried with- 
out benefit. I have found that insulation and the abstrac- 
tion of heavy sparks from the seat of pain give the best 
results. 

Catalytic Action of Electrical Currents. — Under 
this heading we include (1) an increase of absorption pro- 
duced by dilatation of the capillary blood-vessels and lym- 
phatics ; (2) an increased capability of tissues for imbibi- 
tion of fluids, through an increase of osmotic processes ; 
(3) changes in the disassimilation and nutrition of nerves, 
on account of their stimulation or "refreshing effects; (4) 
changes in the molecular arrangement of tissues, caused by 
electrolytic processes; and (5) the results of the transporta- 
tion of fluids from one pole to the other (Remak and Erb). 



July 25, 1885.] 



INOALS: LEU COP LA EI A 



BUCGALIS ET LI NQ UAL IS. 



87 



Remak has shown that muscles become congested and 
greatly swollen when subjected to galvanism. They are 
rendered tense, and (according to this observer) absorb 
water more freely than muscle which has not been galva- 
nized. 

Changes of a marked character may be induced in the 
skin by galvanism. These have been studied by Erb, Re- 
mak, Bollinger, and others. 

The vaso-motor nerves may be influenced by electrical 
currents. This is shown by many of the later investiga- 
tions — prominently those of Loweufeld, which demonstrate 
that contraction and dilatation of the vessels of the brain 
result, respectively, from antero-postcrior and transverse cur- 
rents through the head from a galvanic battery. 

Although we are, as yet, unable to speak with positive- 
ness regarding the certainty of the catalytic effects of elec- 
trical currents, or to map out the forms of disease which 
are to be regarded as specially indicating these catalytic 
effects, still it may be said that the following states have 
been successfully treated by electrical currents, and that the 
cures are probably to be attributed to a catalytic action : 
(1) Inflammatory affections of the nervous system, includ- 
ing sclerosis, myelitis, neuritis, etc. ; (2) arthritis and 
chronic exudations into joints; (3) glandular enlargements ; 
(4) hard cicatrices, periosteal swellings, and fibrous adhe- 
sions ; (5) contusions, sprains, extravasations of blood, and 
other results of traumatisms. 

The galvanic current is the one that is generally em- 
ployed when catalytic effects are desired. In diseased con- 
ditions of the brain, spinal cord, or any of the deeply 
seated organs, the faradaic currents are not usually produc- 
tive of benefit. 

The " stabile method " of application of the galvanic 
current is preferable, to my mind, when catalytic action is 
to be attained. The strength of the current should be suf- 
ficient to easily overcome the resistance offered, and the 
duration should be sufficiently prolonged to accomplish 
changes in the tissues subjected to its influence. One pole 
is placed, as a rule, at an indifferent point (the sternum by 
preference), and the other over the tissue diseased. Some- 
times, as in the case of the brain, for example, the poles are 
placed upon either side of the diseased part. Although 
there are exceptions to the rule, it is well to use the anode 
or positive pole over the diseased part when pain is pres- 
ent, when symptoms of active irritation exist, or when the 
morbid processes are very active. The cathode or negative 
pole is best adapted to influence chronic morbid processes, 
such as sclerosis, indurations, etc. Erb recommends that 
the polarity of the current be changed several times in 
either case ; he doubts the infallibility of the rule given, 
although it is theoretically sound. Chvostek urges the use 
of short and moderate currents for a few minutes (three to 
ten) when catalytic action is desired. In this way, he 
believes, the vaso-motor and trophic nerves are more im- 
pressed than by any other method. 

Respecting the catalytic action of faradaic currents, a 
difference of opinion exists between authors of note. One 
thing is certain — viz., that strong currents are required, and 
that the currents must be passed directly through the dis- 



eased part to accomplish marked results. Glandular tumors 
have been resolved by this method with great rapidity in 
some recorded instances. 

( To be continued.) 



(Jprirjinal Communications. 

LEUCOPLAKIA BUCCALIS ET LINGUALIS, 
OR ICHTHYOSIS LINGUAE; 

SUCCESSFUL TREATMENT WITH THE GALVANO-CAUTERY* 
By E. FLETCHER INGALS, M. D., 

PROFESSOR OP LARYNGOLOGY IN THE RUSH MEDICAL COLLEGE, AND OF DIS- 
EASES OF THE THROAT AND CHEST IN THE WOMAN'S MEDICAL COLLEGE, 
CHICAGO. 

During the past year it has been my good fortune to 
cure a case of the rare and intractable disease which forms 
the subject of this paper. 

This disease has been recognized but a short time, and 
very little can be found upon the subject in general medical 
literature, but, by a thorough search in the library of the 
Surgeon-General's Office in Washington, I found about fifty 
papers, mostly reports of cases, which, with the single ex- 
ception of one by Bazin, which I take second-hand, seem to 
embrace all that has been written concerning the disease. 

The literature is involved in what at first seemed inex- 
tricable confusion, for the reason that several different affec- 
tions have been confounded and described under the same 
name. Thus, " smokers' patches," the peculiar condition of 
the mucous membrane of the mouth found in old glass- 
blowers, termed by Guinaud f " professional patches," psori- 
asis lingua?, and various manifestations of syphilis, have 
been considered by different authors as true leucoplakia, or 
as one of its phases. 

The term leucoplakia, which, of the names proposed for 
this affection, seems open to least objection, was suggested 
by Professor Schwimmer,J who gives a lengthy and exhaust- 
ive description of the disease. Ullmann * employed the 
term tylosis, which is strongly advocated by W. Fairlie 
Clarke. I The affection was first brought prominently before 
the profession by J. W. Hulke, A under the title ichthyosis 
linguae, a name which has been (mite generally accepted 
save by Debove () and some other French writers, who have 
described it, together with other affections, as a manifesta- 
tion of psoriasis. 

Definition. — Leucoplakia buccalis is a chronic affection 
of the buccal mucous membrane, characterized by thickening 
of the epithelium, and the formation of white, opaline, ele- 
vated patches, whicfi usually become fissured ami painful, 
and, after continuing for a long time, are likely to terminate 
in epithelioma. 

* Read before the American Laryngological Association, June '24, 
1885. 

f "Syphilis des reniers," "Lyon nied.," xnxv, 1880. 
\ " Vierteljahresschrift fur Dermatologie," iv, 1877. 

* "Aer/.tlich. Intelligenzblatt," Munich, v, 1858. 
|| " British Med. Jour.," 1874, vol. i. 

A "Med. Times and Gazette," London, 18f>f>, vol. i. 
v Paris thesis, 1873. 



88 



1NGALS: LEUCOl'LAKIA BUCCALIS ET LINGUALIS. 



[N. Y. Med. Jock., 



History. — The first mention that I can find of ichthyosis 
lingua? is in a paper under the title of "Maladies de la 
peau," 1822, by Alibert, who records a case, reported in 
some of the journals, of a young woman in Naples who had 
extensive ichthyosis of the skin, which finally involved the 
tongue and lips. In 1837 Samuel Plumbe* described a 
case of enlargement of the papilla; of the tongue which lie 
regarded as precisely similar in its nature to local ichthyo- 
sis of the skin. In 1858 Ullmann f described a case of leu- 
coplakia under the name of tylosis. In the same year J. J. 
Buzenet J reported two cases of undoubted leukoplakia, and, 
in 1861, J. W. Hulke* recorded a case under the title of 
" Wart and Corn of the Mucous Membrane of the Tongue." 
The following year Sir William Fcrgusson || presented a 
somewhat similar case in a clinic at the King's College Hos- 
pital, and in the same year, in the report of a clinic by Dr. 
Andrew Clark, A we find a case described under the name of 
aphtha figurata, which is supposed by some to have been true 
leucoplakia, but which seems to have been psoriasis of the 
tongue. The same year J. Moore Neligan v notes a case of 
true leucoplakia which finally terminated in epithelioma. 
February 28, L865, .1. W. Hulke, J of London, presented what 
is generally credited as the first paper on the subject to the 
Royal Medical and Chirurgical Society. Subsequently brief 
articles appeared on the subject by S. James A. Salter,^ 
1866; Bazin,J 1868; M. Lailler,** 1869.; Sir James Paget,ff 
1870; C. Saison,JJ 1871 ; and W. Fairlie Clarke** 1872. 
Finally, in 1873, Charles Mauriac |||| published an exhaustive 
article on the subject under the title of " I >u psoriasis de la 
(angue et de la muqueuse buccale." Since Mauriac's article 
numerous papers have appeared, the most important of 
which are by M. G. Debove, AA 1873 ; Henry Morris,^ 1874 ; 
W. Fairlie Clarke,J J the same year ; Robert F. Weir,|J 1875 ; 
Professor Ernst Schwimmer, JJ 1877 and 1881; and E. 
Vidal,*** 1883. 

The disease is very rare, but its frequency can not 
be accurately determined, on account of the diversity of 
opinion which has been entertained by different writers 
with reference to its aetiology and diagnosis — a diversity 
which has caused many cases to be placed in this class 
which do not properly belong in it. Professor Schwimmer 
saw only twenty examples out of five thousand cases of 

* "Diseases of the Skin," Philadelphia, 183V. 

\ Loc. cit. \ Paris thesis, 1858. 

* "Med. Times and Gazette," London, 1861, vol. ii. 
I "Lancet," London, 1862. 

A "Med. Times and Gazette," London, 1862, vol. ii. 

0 " Notes of an Unusual Abnormal Condition of the Mucous Mem- 
brane of the Tongue and Cheeks considered in Connection with Life 
Assurance," 1862. 

% Lor. cit. % "Papillary Tumors of the Gums," 1866. 

| Paris thesis, 1873. 

** " Diet, encycl. des sci. med.," Paris, 1 869. 
ft "Case of Cancer following Ichthyosis of the Tongue," 1870. 
}4 Paris thesis, xlvi, 1871. ** "Lancet," London, 1872, vol. i. 
|| || "L'Union medicale," xvi, 1873. ^ Paris thesis, 1873. 

v <) " British Med. Jour.," 1874, vol. vi. XX Lf>r - <'''• 

%% "N. Y. Med. Jour.," vol. xxi, 1875. 

\\Loc. cit., and " Transactions of the International Med. Cong.," 
London, vol. iii, 1881. 

*** "L'Union m6d.," xxxv, 1883. 



diseases of the skin and syphilis, and many others have not 
seen so large a proportion as this ; but doubtless many cases 
are not recognized, and pass for constitutional syphilis. 

Most of the cases have been reported from Germany, 
France, and England, but some have been recorded in this 
country. So far the records show that the disease seldom 
affects any excepting males over forty years of age, though 
it has been observed as early as the thirty-second year, and 
a very few examples have been seen in women. 

Anatomical Characters. — The patches are generally 
found on the dorsum of the tongue or the inner surface of 
the cheek and lips, but seldom, if ever, on the lower surface 
of the tongue or behind the anterior pillars of the fauces, and 
they are limited to the buccal cavity. 

They may be seen in one or more small, irregular, or 
oval patches, or these may have become confluent. A con- 
siderable portion of the tongue alone may be involved, or 
the dorsum of the tongue, the buccal mucosa, and the sur- 
face of the jaw may one or all be affected. 

The first appearance of the white patch is preceded by 
hyperemia, and in the early stages a hypenemic areola is 
found about its borders. Afterward the patch itself is more or 
less thickened, sometimes to the extent of six or eight mm., 
and the epithelium, which has become hard and dry, may be 
easily removed, or in spots it may have been spontaneou-l v 
exfoliated, leaving the appearance of an ulcer. 

The surface of the patch is marked by numerous fine 
lines or furrows, wbich intersect each other, dividing it into 
small polygonal spaces. Some of these may extend as deep 
fissures down through the thickened epithelium, and in- 
volve the mucosa in painful ulceration. In cases of lon<>- 
standing the papillae may be much enlarged, giving the sur- 
face a warty appearance. 

Under the microscope the epithelium is found greatly 
thickened, tbe papilla; enlarged and flattened, the blood- 
vessels dilated, with an accumulation of leucocytes about 
their walls. The superficial layer of the mucous corium is 
infiltrated with embryonic cells, and the deep layer is in- 
volved in vascular alterations. 

According to Hulke,* there is hypertrophy of the epi- 
thelial and papillary layer of the mucous membrane, similar 
to the condition of the skin termed ichthyosis. 

In 1874, W. Fairlie Clarke f spoke of the disease as a 
chronic inflammation and papillary growth, but in later 
writings he does not strictly adhere to these views. 

Mauriac J says "it is certain that it is a chronic inflam- 
mation of the parts involved." 

In the first stage of the affection, hypera?mia of the 
deeper layers of the epithelium exists, which is soon fol- 
lowed by exudation, and this consolidating causes indura- 
tion. 

The epithelial cells are increased and the papilla? en- 
larged, but later, when the affection merges into epithelioma, 
there is, according to Clarke,* an enormous increase of the 
rete mucosum at the expense of the papilla?, which are then 
reduced to mere threads. 

Causation. — Excessive tobacco-smoking is ranked as one 
of the most frequent causes of the disease, but it is barely 

* Loc. cit. f Loc. cit. \ Loc. cit. * Loc. cit. 



July 25, 1885.] 



INQALS : LEU COPLAKIA BUGGALIS ET LINOUALIS. 



89 



possible that prolonged irritation of any character muy 
have a similar effect on those predisposed to it. 

Thus, Mauriac * and Vidal f mention highly spiced foods 
and alcoholic stimulants as irritants which must be avoided. 

SchwimmerJ calls the affection idiopathic, but both 
he and Mauriac think there must be some peculiar pre- 
disposition toward it in order that it may be developed. 

Bazin,* who has seen the affection in several members 
of the same family, believes that it is often, if not usuallv, 
the result of constitutional syphilis. 

Mauriac believes that all psoriasis of the mouth and 
tongue supervening in syphilis is not necessarily syphilitic, 
and may not take part in the syphilitic disease. 

Debove, Bazin, and Mauriac attribute it frequently to 
the arthritic or dartrous diathesis. Thus it will be seen 
that the cause of the affection is not definitely known, 
though it is commonly believed to be induced by smoking 
in most instances. It must not be forgotten, however, that 
several cases have been recorded in persons not addicted to 
the use of tobacco. In those who use tobacco to excess it 
is not necessarily the irritant effects of the smoke or heat 
that cause the disease, but, as in the case here appended, the 
noxious influence of the tobacco itself. 

Clinical History. — It is also difficult to determine exact- 
ly the duration of the disease, for it has generally been dis- 
covered accidentally ; but usually it will be found to have 
existed for months or years when the patient first presents 
himself. This is due to the fact that at first the affection 
causes no inconvenience. Usually the small patch first ob- 
served gradually increases in size until at length stiffness of 
the part occurs or painful fissures form, which cause the pa- 
tient to seek advice. 

In some cases the epithelial cells gradually pile up until 
a thick, horny mass is formed, which may then be thrown off 
spontaneously or pared off by the patient as he would cut 
off a corn or wart. After a time, varying from a few months 
to many years, the formation of fissures and ulcers causes 
pain, and finally, in a large percentage of cases, epithelioma 
results and runs its usual course. Sometimes the affection 
will remain stationary for months, or, under the influence of 
some irritant, it may rapidly progress, but may again become 
dormant if the irritant is removed. Occasionally unchang- 
ing erythematous patches remain in the surrounding mucous 
membrane for years. 

In the cases associated with syphilis and in those that 
have developed into epithelioma the parts become greatly 
swollen, and deep, fungous ulcers occur which may erode 
vessels and cause serious haemorrhage. In these same cases 
the lymphatic glands are involved, but this does not occur in 
the earlier stages of idiopathic leucoplakia. 

Often the first symptom noticed by the patient is simply 
an uneasy sensation ; but this may not appear until the dis- 
ease has existed for years. In other cases the mucous mem- 
brane early becomes sensitive, so that spices, hot food or 
drinks, alcoholics, tobacco, etc., cause more or less pain. 
When deep fissures occur, the pain may become intense and 
almost constant, though in some cases it is present only at 



intervals. There are no constitutional symptoms until epi- 
thelioma is developed. Late in the disease, speaking, mas- 
tication, and swallowing sometimes become difficult, espe- 
cially when epithelioma occurs. In such cases there is also 
profuse and very troublesome salivation, which continues 
both night and day. 

Upon examining the mouth in the early stages, several 
more or less oval red or white patches are usually found 
which are apt to be mistaken for secondary syphilis. These 
in time become bluish, and finally, with increase in their epi- 
thelial covering, grayish or of a milky white color — like mu- 
cous membrane touched with nitrate of silver. These spots 
may remain distinct for a long time, but with the progress 
of the disease they become confluent, and at length form 
large, irregular patches. At first the surface of the patch is 
usually smooth, marked only by fine intersecting fissures, 
and is but slightly elevated above the surrounding mucous 
membrane. At this time the papilbe are often prominent 
and large, but, as the epithelial cells accumulate, they 
atrophy and are buried out of sight, and the surface may 
become raised several millimetres above the healthy mu- 
cous membrane. In some instances we find that a portion 
of the horny mass has been thrown off, and has left a 
central depression which may be ulcerated. These latter 
changes take place only in those cases which have been ex- 
posed to great irritation or which are approaching the stage 
of epithelioma. About the younger and growing patches 
we find an erythematous border, but this finally disappears. 
In cases associated with syphilis, cicatrices and nodosities 
or deep fissures of the tongue are usually found, and, in 
those which have passed into epithelioma, induration and 
thickening of the subjacent tissues, with deep, unhealthy 
ulcers, are likely to be present. 

Diagnosis. — Leucoplakia is liable to be mistaken for 
what Guinaud * has termed the " professional patches," 
found in glass-blowers, for " smokers' patches," mercurial 
patches, psoriasis linguae, syphilitic patches, and epithe- 
lioma unconnected with leucoplakia. The "professional 
patches" occur only in old glass-blowers, particularly in 
bottle-makers, and are found symmetrically upon both sides 
of the mouth, on the lateral surface of the jaw, and around 
Stenson's duct. " Smokers' patches " are more irregular 
in seat than those of leucoplakia, and are commonly locat- 
ed near the commissures of the lips, but not upon the dor- 
sum of the tongue or inner side of the cheek. Again, the 
epithelium covering their surfaces is thin and closely ad- 
herent, so that it can not be removed, as in the disease 
under discussion. Mercurial patches are not so thick as 
those of Jeucoplakia, are never quite white, and are found 
on all parts of the tongue, but particularly where it is 
pressed against the teeth. According to W. Fairlie Clarke, f 
psoriasis is an affection in which circumscribed patches of 
epithelium assume a white, opaque appearance, which, after 
a day or two, are thrown off, when the epithelium is speed- 
ily restored; but soon other patches appear and go through 
the same course, until, after a time, the whole surface of 
the tongue becomes denuded and of a uniform red color. 



* Loc. cit. f Loc. cit. \ Loc. tit. * Loc. tit. 



* Jjoc cit. 



f Loc. cit. 



90 



INGALS: LEUCOPLAKIA BUCCALIS ET LING HALTS. [N. Y. Med Joub., 



with crescentic markings or depressions, which, it will be 
observed, is rery unlike the course of leucoplakia. Syphi- 
litic patches are not so white as those of leucoplakia ; they 
are usually round or oval, and more regular in form, and 
they seldom occur on the cheek, but are found principally 
on the tip or margins of the tongue, and often on its lower 
surface, which is never invaded by leucoplakia. Syphilitic 
patches do not become so thick as those of leucoplakia, 
and in syphilis the lymphatic glands are soon involved, 
which is not the case in the latter unless it has become can- 
cerous. The pain is more severe in leucoplakia than in the 
syphilitic disease, and anti-syphilitic treatment causes no 
improvement, but may aggravate the affection. When 
syphilis and leucoplakia co-exist, the diagnosis is difficult, 
and sometimes can only be cleared up by specific treatment. 
Cancer arising without previous leucoplakia is distinguished 
from the latter by its history. In cancer, the induration of 
tissues and the final ulceration are not preceded by the 
chronic white patch, and are attended by more constant 
pain, with profuse salivation and a very offensive odor. 

Prognosis. — The duration of the disease is uncertain 
One authority mentions two cases in which cancer super- 
vened in less than six months. Sir James Paget * mentions 
one case which terminated in cancer at the end of eighteen 
months, several of Mauriac's \ were of eleven to thirteen 
years 1 duration, while of the two cases seen by Hulke, J 
which terminated in this way, one had existed twenty 
years. Others have mentioned cases of thirty to fortv-five 
years' duration. Debove* and Bazin,|| who make no clear 
distinction between leucoplakia and syphilis, and Kaposi, A 
who speaks of leucoplakia as a universal product of syphilis, 
very naturally believe that the affection is frequent, that it 
does not terminate in cancer so often as we should suppose 
from the writings of others, and that it is very amenable to 
treatment. Schwimmer Q says that the diseaFe is frequently 
transformed into malignant formations and ends fatally, 
and the general belief is that it is very likely to end in epi- 
thelioma. Yidal J believes that one half the cases terminate 
in this way. On this point Mauriac| says that "transfor- 
mation into epithelioma has often been noted, therefore it 
is important to cure the superficial affection, or it may pass 
into a deep, destructive, mortal disease." 

The same author thinks that there are three varieties of 
leucoplakia (or, as he terms it, psoriasis lingua;). One, 
which he says is curable (due to syphilis), we do not 
think belongs to this class of diseases. The others he 
considers incurable. The variety which he attributes to 
the arthritic or dartrous diathesis he terms innocuous, 
while the third variety — the epitheliomatous — is incurable 
and malignant. 

Among the indications that leucoplakia is passing into 
epithelioma are : non-inflammatory enlargement of the lym- 
phatic glands, with exfoliation of the thicker portion of 
the patch, the formation of an ulcer, the supervention of 
sharp pain, salivation, and at length induration of the sub- 
jacent tissues. Finally, great swelling in the region of the 

* Loc. cit. \ Loc. cit. \ Loc. cit. * Loc. cit. || Loc. cit. 
A "Syphilis der Haut," Wien, 1876, vol. iii. 

Q Loc. cit. % Loc. cit. $ Loc. cit. 



jaw is likely to occur, and death takes place from exhaus- 
tion. 

Treatment. — In cases of leucoplakia all sources of irrita- 
tion, particularly those resulting from the use of tobacco 
and alcoholic stimulants, should be at once removed, and if 
the digestive organs are deranged, as is frequently the case, 
they should receive proper attention. Aside from these 
measures, most authorities believe treatment of little or no 
avail. Schwimmer* says that local* treatment is not ra- 
tional ; that alkaline washes and the waters of Vichy and St. 
Christan, and other alkaline waters, though highly recom- 
mended by Bazin f and other French writers, are not satis- 
factory in their effects ; and that, even if improvement does 
occur under their use, it is not likely to be enduring. 
Debove \ and Bazin state that many cases of buccal psoria- 
sis may be cured, but their favorable results may be due to 
the fact that they included many syphilitic cases in this class. 
By an examination of Debove's recorded cases, I find that, 
exclusive of the syphilitics, none of the patients seem to have 
been entirely cured, though many were treated by both Bazin 
and Debove, and a number are reported as " something 
better " after several months of treatment. Mauriac,* who 
believes that there are three varieties of leucoplakia — viz. : 
1, the dartrous and arthritic; 2, the syphilitic; 3, the epi- 
theliomatous — recommends arsenic and alkalies for the first, 
mercury and iodides for the second, and surgical measures 
for the third ; however, he urges great prudence in using 
any of these measures, and states that the internal remedies 
have been found almost useless, and that mercury and the 
iodides are dangerous in the absence of syphilis. 

For local application, the caustics which have commonly 
been employed are nitrate of silver, chloride of zinc, tinc- 
ture of iodine, and acid nitrate of mercury ; but none of 
them seem to do any good excepting in syphilitic cases, 
which I do not include under the term leucoplakia. Sooth- 
ing applications seem to have been most beneficial, but they 
give only temporary relief. 

E. Vidal || says that " mercury and iodide of potassium 
aggravate the disease the more advanced it is," and that in 
the papillomatous state they precipitate epithelioma. When 
the affection has passed into epithelioma nothing can be of 
much benefit excepting thorough excision, but even this 
has not often been followed by happy results. 

Henry Morris A advises that, after other measures have 
been fairly tried, if the epithelium is constantly thrown off, 
leaving abrasions or ulcerations which are painful, the 
tongue should be excised without delay. He states that 
" the prospect of curing, or even much improving, ichthyosis 
by treatment is most unfavorable." 

S. James A. Salter Q reported a case, which seemed to 
have been leucoplakia, which was cured by extirpation and 
cauterization of the wound with the actual cautery. In the 
case which I report it will be observed that internal reme- 
dies did no good, and that local applications of tincture of 
iodine, nitrate of silver, and the acid nitrate of mercury 
greatly increased the patient's sufferings, and would doubt- 
less have aggravated the disease had they been persisted in ; 

* Loc. cit. f Loc. cit. J Loc. cit. * Loc. cit. 

I Loc. cit. A Loc. cit. v Loc. cit. 



July 25, 1885.1 



IN GALS: LEVCOPLAKIA BUCCALIS ET LINO UA LIS. 



91 



but, as soon as the actual (galvanic) cautery was employed, 
relief from all pain was obtained, and by a persistent, care- 
ful use of it the disease was eradicated. 

In considering this favorable result, of course we must 
not overlook the reported tendency of the disease to recur ; 
but the fact remains that the belief in this tendency is based 
on a study of cases in the majority of which the diseased 
patch was never entirely removed. In my case the mucous 
membrane is perfectly healthy after a lapse of four months; 
therefore I believe the treatment adopted for it will prove 
curative in many cases if applied before epithelioma has 
developed. 

From a study of the literature of this subject, and from 
my own small experience, I arrive at the following conclu- 
sions : 

1. Leucoplakia buccalis is an idiopathic disease, distinct 
from psoriasis, " smokers' patches," and syphilis. It is 
largely confined to men past middle life, but it occasionally 
occurs in women. 

2. The disease is so commonly found in inveterate 
smokers that the abuse of tobacco may fairly be considered 
as au exciting cause, though cases occur where tobacco has 
never been used. 

3. The affection is chronic and, finally, in a majority of 
cases, terminates in epithelioma. 

4. Internal treatment and the local application of seda- 
tive, stimulant, or caustic drugs are, in nearly all cases, either 
useless or injurious, and the latter are sometimes disastrous 
by hastening the development of epithelioma. 

5. The actual cautery or the galvano-cautery will prob- 
ably enable us to cure many cases if they are treated suffi- 
ciently early, provided it is applied to only a small spot at 
each sitting, and carefully, so as not to destroy the healthy 
tissues beneath the changed epithelium. 

A Typical Case. — L. 0., aged forty-three, printer, came to 
me in September, 1884, complaining of a sharp pain in the left 
side of the mouth, particularly when eating. This, he said, began 
two years before, when he had a tooth drawn. Two months 
later he first noticed a small white patch on the buccal raucous 
membrane. Upon examining the mouth, I found a large, irregu- 
lar, milk-white patch, extending from the border of the gums 
down through . the gingivo-buccal groove, upward along the 
left cheek, and from the first bicuspid tooth, in front, to the 
last molar, behind. Altogether this was as large as a silver 
dollar; its surface was marked by fine intersecting lines, which 
divided it into numerous polygonal spaces. 

At the center of the patch, on the buccal surface, was a de- 
pression about 3 mm. in depth and 1 era. in diameter, sur- 
rounded by elevated, hard margins, which gradually became 
thinner toward the edge of the patch. This margin was deeply 
fissured in two or three places. About half an inch in front of 
the anterior portion of this patch, on the UDder lip, was a small, 
white, warty growth, about 4 mm. in height by 3 mm. in 
diameter. 

A critical investigation of the case failed to discover any his- 
tory or signs of syphilis or hereditary disease. The patient 
chewed tobacco to excess and had smoked occasionally. He 
stated that previous to the removal of the tooth, and until the 
pain became troublesome, he had been accustomed to carry his 
quid of tobacco in the left side of the mouth, at the location of 
the patch. His general health was perfect, and ho had never 



suffered from rheumatism or eruptive diseases, and did not use 
alcoholic stimulants. During the first few months of the affec- 
tion paiu came on about once in two weeks and would last sev- 
eral hours, but the attacks gradually became more frequent, un- 
til seven or eight weeks before I saw him, during which time 
the pain had been constant and often severe. The patch had 
been cauterized occasionally with nitrate of silver, but was never 
benefited. 

When I first saw the case, suspecting that it might be syphi- 
litic, I ordered iodide of potassium in large doses and directed 
that tobacco be discontinued. I cauterized the patch with tinc- 
ture of iodine, but the application caused such severe and pro- 
tracted smarting that I began at once to be doubtful about the 
character of the disease. Three days later I applied the solid 
nitrate of silver to a small portion of the patch, with similar re- 
sults, and four days later the acid nitrate of mercury. This last 
application caused intense pain that lasted about seven hours, 
which, he said, drove him nearly crazy. I was now convinced 
that the disease was not syphilitic, and had the patient see Pro- 
fessor Hyde, who pronounced it leucoplakia. I next cauterized 
the central depressed portion of the patch with the galvano- 
cautery, which caused momentary smarting, but perfectly re- 
lieved the severe pains from which he had suffered for weeks, 
and they never returned. Two days later I destroyed the small, 
wart-like projection in front of the large patch, and subsequent- 
ly, about every fifth or sixth day, I cauterized a small spot, 
nearly a centimetre in diameter, at the edge of the patch. 
These cauterizations were so superficial that only the epitheli- 
um was destroyed, the membrane beneath being but slightly 
burned ; indeed, so light were they that a few times I was 
obliged to again cauterize the same spot before all the epithe- 
lium was destroyed. I found that as these* cauterized places 
healed the mucous membrane appeared natural, and finally, 
after about thirty applications of the cautery, the entire surface 
presented the appearance of healthy mucous membrane, show- 
ing only two or three small cicatrices, where the cauterizations 
had been unusually deep. The iodide of potassium, which did 
no good, was discontinued soon after I began the use of the gal- 
vano-cautery. Now, at the end of four months after the last 
cauterization, the mucous membrane remains perfectly healthy. 

Bihliography. 
Alibert. "Maladies de la peau," Paris, 1822. 
Bazix. " Psoriasis buccal," Paris thesis, 1873. 
Buzenet, J. J. A. " Chancre de la bouche," Paris thesis, 
225, 1858. 

Church, William. "Report of a Case of Ichthyosis, with 
Congenital Malformation of the Aorta," 1865. 

Clark, Andrew. "Aphtha Figurata ; Clinical Remarks on 
its Pathology and Treatment," " Medical Times and Gazette,'' 
vol. i, 1862. 

Clarke, W. Fairlie. " Case of Ichthyosis Lingua?," " Lan- 
cet," vol. i, 1872. See also "British Medical Journal, - ' vol. i, 
1874; "Practitioner," London, vol. xiii, 1874; "Lancet," 
vol. i, 1874. "Cases of (so-called) Ichthyosis Lingua\" "Mod. 
Chir. Trans.," 1874, vol. ii. "Exfoliation of the Tongue," 
1882. 

Debove, G. M. " Psoriasis buccal," Paris thesis, 1873. " I)u 
psoriasis buccal," "Archives gen. de med.," xxiii, 1874. 

Devergie. " L'Union mod.," xxii, 1876. 

Febgtjssoit, Sir William. " Clinical Remarks on a Peculiar 
Form of Disease of the Jaw in an Aged Patient," "Lancet," 
1862, vol. ii. 

Fox, Tilbury. "So-called Ichthyosis Lingua? and its Re- 
lation to Ichthyosis," from "British Medical Journal," 1874, 
vol. i. 



92 



WES TBROOK : ANTIPYRINE IN SUNSTROKE. 



[N. Y. Med. Jour.' 



Fournier, Alfred. " Des glossites terti:iires>," Clinical 
Lectures, " La France med.," xxiii, 1876. 

Fredet. "Bull, et mem. <le la soc. de chir. de Paris," vol. 
ii, 1876. 

Gavtier. •' De la desquamation epitheJiale de la langue," 
"Revue med. de la Suisse romande," 1881, vol. i. 

Goodhart, James F. " On Cancer, as illustrated in Ichthy- 
osis of the Tongue and Allied Diseases resulting from Prolonged 
Local Irritation," "Guy's Hospital Reports," Third Series, vol. 
xx, 1875. 

Guinaud. " Syphilis des reniers." " Lyon med.," xxxv, 
1880. 

Httlke, J. W. " Wart and Corn of the Mucous Membrane 
of the Tongue," "Med. Times and Gazette," London, 1861, 
vol. ii. " Ichthyosis of the Tongue," from " Med. Times and 
Gazette," 1865, vol. i, London. See " Proceedings of the Royal 
Med. and Chir. Soc," 1865, vol. v, London. 

Hugonneau. Report of a case of glossitis, ending in epi- 
thelioma. Paris thesis, 431, 1876. 

Kaposi. "Syphilis der llaut," Wien, 1875, vol. iii. 

Krueg, Julius. "Leucoplakia linguae bei einem Geistes- 
kranken mit Vergiftungsideen," " Wien. med. Woch.," 1878. 

Leloir. "Progres mod.," Dec. 15, 1883. 

Lailler, M. Art. "Bouche," "Diet, encycl. des sci. med.," 
vol. x, Paris, 1869. 

Mauriac, Charles. " Du psoriasis de la langue et de la 
muqueuse buccale," " L'Union medicale," xvi, 1873. Definition 
based upon anatomo-pathological constituents of bucco-lingual 
psoriasis, Ibid., xvii, 1874. 

Morris, Henry. "Remarks on Ichthyosis Linguae followed 
by Epithelioma Linguae," with notes of three cases, " British 
Med. Journal," Feb. 21, 1874. See "British Med. Journal," 
March, 1874, London. " Remarks on Epithelioma and Ich- 
thyosis of the Tongue, based on Records of Seventy-five Cases," 
"Lancet," 1882. 

Merklen, P. t " Psoriasis buccal de Bazin," " Annales de 
derm, et de syph.," vol. iv, 1883. 

Nedophil, M. " Ueber die Psoriasis der Zungen- und Mund- 
schleimhaut und deren Verhiiltniss zum Carcinom," Langen- 
beck's "Arcbiv," Berlin, vol. xx, 1877. 

Neligan, J. Moore. " Notes of an Unusual Abnormal Con- 
dition of the Mucous Membrane of the Tongue and Cheeks con- 
sidered in Connection with Life Assurance," 1862. 

Paget, Sir James. " Case of Cancer following Ichthyosis of 
the Tongue," 1870. 

Plumbe, Samuel. "Diseases of the Skin," Philadelphia, 
1837. 

Rigal, Aug. Art. " Langue," " Nouv. diet, de med. et de 
chir.," vol. xx, Paris, 1875. 

Saison, C. " Syphilides sur la langue," Paris thesis, xlvi, 
1871. 

Salter, S. James A. " On Papillary Tumors of the Gum," 
1866. 

Schwimmer, Ernst. " Die idiopathischen Schleimhaut- 
Plaques der Mundhohle ; Leucoplakia buccalis," " Vierteljahres- 
schrift fur Dermat. und Syph.," iv, v, 1877, 1878. See " Trans- 
actions of the International Med. Congress," vol. iii, 1881. 

Trelat, . Relations between psoriasis and epithelio- 
ma of the tongue, " Bull, et m6m. de la soc. de chir.," vol. i, 
1875, and vol. ii, 1876. 

Ullmann, . " Schwielenbildung auf der Zunge," 

"Aerztlich. Intelligenzblatt," Munich, v, 1858. 

Vidal, E. Clinical lecture at the Hopital St. Louis on buccal 
leucoplasia, "L'Union med.," xxxv, 1883. 

Weir, Robert F. " Ichthyosis of the Tongue and Vulva," 
« New York Med. Jour.," xxi, 1875. 



NOTE ON THE USE OE ANTIPYRINE IN 
SUN ST HOKE. 

By BENJAMIN F. WESTBROOK, M. D., 

PHYSICIAN IN CHIEF TO THE DEPARTMENT OF DISEASES OF THE CHEST. 
ST. MAHY'S GENERAL HOSPITAL, BROOKLYN. 

My object in publishing this note is to call attention to 
the use of antipyrine in two cases of sunstroke, so that others 
may, if they think proper, test it and contribute the results 
of their experience. 

It occurred to me that the prompt introduction of an 
antipyretic dose of this substance into the subcutaneous 
tissues might be of great service in reducing- the tempera- 
ture, and so give time for attention to the treatment of the 
other pathological conditions. The ambulance surgeon, Dr. 
Polker, was therefore requested to provide himself with a 
fifty-per-cent. solution, and, in the event of his being called 
to a case of the apoplectic form of the disease, to administer 
a drachm of the solution hypodermically at once, and to re- 
peat it in an hour, if the temperature was not markedly 
reduced. Other measures for the relief of the patient were, 
of course, not to be neglected. 

On Saturday, the 18th, when the thermometer registered 99' 
F. in the shade, he was called to attend a young Englishman, 
twenty-two years old, of very robust habit, who, after working 
out of doors all the forenoon, became comatose and convulsed 
after reaching his home at midday. The head was congested, 
eyes suffused, pulse rapid and strong, skin dry, and the coma 
profound. The bowels had moved spontaneously, and he had 
vomited freely. The rectal temperature was 109° F. The doc- 
tor administered a drachm of the fifty-per-cent. solution of anti- 
pyrine hypodermically, applied ice to the head, and removed 
him to the hospital. 

In the confusion attending his admission the exact time was 
not noted, but in about three quarters of an hour after the first 
dose the rectal temperature was 107 - 50° F. Cold was applied to 
the body and head by means of towels wrung out of ice-water 
and frequently changed; and another drachm of the solution 
was introduced under the skin. In thirty minutes the rectal 
temperature was again taken and found to be 99° F. The cold 
applications were at once discontinued and dry heat was ap- 
plied to the surface, while whisky was injected subcutaneously. 

When I arrived shortly afterward the surface of the body 
was cool, the pulse 120, the coma profound, and all the limbs 
were twitching convulsively. The head was still congested, 
the conjunctivae injected, the pupils contracted but responding 
feebly to light, and the respiration was irregular and accom- 
panied by a loud expiratory groan, such as is heard in severe 
cerebral disturbance. I gave two ounces of whisky and forty 
grains of chloral hydrate by enema, but they were not retained. 
About half an ounce of whisky was then given hypodermically. 
In half an hour the temperature began to rise slowly, so that 
the surface was warm. The twitching of the voluntary mus- 
cles became more marked, and he was seized with a most vio- 
lent tetanic convulsion, which was controlled by chloroform. 
As the convulsions succeeded each other with increasing rapid- 
ity and intensity, I opened the median basilic vein and with- 
drew thirteen ounces of blood. The bleeding was terminated 
sooner than was desirable by the onset of a terrific convulsion, 
during which the arm was twisted violently and the opening in 
the vein occluded. After this there were no more severe con- 
vulsions ; the patient became more quiet, and the rectum re- 
tained forty grains of chloral hydrate. This was followed by a 



July 25, 1885.] 



STUB: CHOLERA ASIATIC A 



AND CHOLERA NOSTRAS. 



93 



period of rest, during which the axillary temperature was taken 
and found to be 103-75° F. 

One drachm of Lente's solution was thrown under the skin, 
and repeated about once in two hours till four doses were ad- 
ministered. At 8.15 p. m., as slight convulsions had occurred 
from time to time, six leeches were applied to the temporal 
regions, twenty grains of antipyrine given hypodermically, and 
forty grains of chloral hydrate by the rectum. From this time 
on- he slept quietly, the temperature slowly declining until Sun- 
day morning, when it was 99° F. 

At about ten o'clock on Saturday evening the patient first 
became sufficiently conscious to partially respond when spoken 
to, and from this he passed into a condition of hebetude, which, 
by Monday forenoon, had given place to complete conscious- 
ness. The temperature has been normal since Sunday after- 
noon, though the pulse is still somewhat rapid. He takes nour- 
ishment well. From Sunday morning to Monday morning he 
had forty grains of sodium bromide every two hours, and five 
grains of the sulphate of quinine every four hours. The doses 
were then reduced to twenty grains and two grains. 

This case represented the severest type of sunstroke. I 
have never before seen so bad a one recover. The tempera- 
ture was high, the coma very profound, and the convulsions 
the most terrible that I have ever witnessed, except in. one 
case of tetanus, the subject of which died within twenty-four 
hours after the diagnosis was made. The rapid and per- 
manent reduction of temperature, which must have been 
mainly due to the antipyrine — inasmuch as the cold appli- 
cations were only continued for half an hour — undoubtedly 
contributed toward the favorable result by giving time and 
removing at once the injurious effect of the hyperpyretic 
blood upon the higher nervous centers. The beneficial 
effect of the abstraction of blood was evident. 

The second case was brought in an hour or two after 
the first, and while I was in the hospital : 

The patient, an Italian laborer, had been engaged in some 
laborious work upon the new btfilding of the St. John's Orphan 
Asylum, which was destroyed by fire last winter. He became 
suddenly unconscious, had well-marked convulsions, and voided 
his excrement involuntarily. When Dr. Folker, our very com- 
petent ambulance surgeon, arrived he was comatose, breathing 
irregularly, with rapid and tense pulse, suffused conjunctivae, 
dry skin, and continual convulsive twitchings of all the volun- 
tary muscles. The rectal temperature was 110° F. The doctor 
gave him a hypodermic injection of one drachm of the fifty-per- 
cent, solution of antipyrine, applied ice to the head, and brought 
him to the hospital. On his admission he was comatose. The 
surface, to my surprise, was cool. The pulse was 120, as nearly 
as it could be counted, with marked tension and a laboring 
stroke of the heart. The respiration was rendered irregular by 
the continued spasmodic movements of the voluntary muscles. 

The convulsive movements of the limbs were very peculiar, 
differing from any that I had seen before, in that they were 
rhythmic in character, and most readily likened to those of a 
man pulling upon a rope. The rectal temperature, thirty-five 
minutes after the administration of the hypodermic injection 
containing one half drachm of antipyrine, was 101° F. 

No cold applications were used in this case, with the excep- 
tion of ice to the head. He was given, by enema, four ounces 
of whisky and thirty grains of the hydrate of chloral, and re- 
tained it. 

After a time he became quiet, the convulsive movements 
almost entirely ceased, and consciousness became dimly percep- 



tible. But, upon changing him to another bed, the peripheral 
irritation threw him into an active tetanic convulsion, which, 
however, soon subsided spontaneously. It was noted afterward 
that any pronounced peripheral irritation would produce con- 
vulsive movement. After an hour he received another half- 
drachm dose of chloral hydrate, with two ounces of whisky, per 
rectum. 

He also received a drachm of Lente's solution of quinine 
about once in two hours. On Sunday morning he was quite 
conscious. The temperature was 99° F. He was ordered 
twenty grains of the bromide of sodium every two hours and 
three grains of quinine every four hours. On Monday his con- 
dition was still better, his mind, apparently, quite lucid, and his 
desire to move about and partake of food very decided. The 
bromide and quinine were continued. 

The favorable termination in both of these cases is sig- 
nificant, as they were both accompanied by great hyperpy- 
rexia and signs of a most profound vital disturbance. The 
first case was, probably, slightly injured by the use of cold 
applications too long continued, but this was quite excusa- 
ble on the part of the house staff, as they were dealing 
with a new remedy, and had been advised not to neglect 
the old ones. The result in the second case would seem to 
strongly indicate that, where antipyrine is used, the exter- 
nal application of cold is not necessary. Another interest- 
ing observation was that, when the temperature declined, 
the cerebral symptoms still continued. This might indicate 
that even a short period of such intense heat and arterial 
excitement may so benumb the vaso-motor apparatus that 
several hours are required for recuperation. 

If this is the correct inference, an agent like antipyrine, 
which is capable of reducing the temperature quickly, may 
be of the utmost importance. 

But, of course, further observation is necessary before 
any positive conclusion can be drawn. From our experience 
so far, I should say that half a drachm of the drug would 
be sufficient to accomplish the purpose. A fifty-per-cent. 
solution is easily made, and, when injected beneath the 
skin, produces very little irritation. 



CHOLERA ASIATICA AND CHOLERA 
NOSTRAS ; 

THEIR DIAGNOSIS AND TREATMENT, 
WITH SPECIAL REFERENCE TO THE BACILLUS. * 
By ARNOLD STUB, M. D., 

BROOKLYN. 

(Concluded from page 36.) 

Those spirilla discovered by Deneke in cheese, and by 
Lewis found in the mucous covering of the teeth, I have 
nothing to do with in this paper; it will be sufficient, I 
think, to mention that they also present different appear- 
ances on cultivation, and that Dr. Lewis's bacillus does not 
grow at all in alkaline or neutral nutritive gelatin. If a 
small particle is taken, with a previously well-sterilized pla- 
tinum wire, from one of the colonies recognized as Asiatic- 
cholera bacilli, and gelatin kept in a test-tube inoculated 
with the same, we shall find that within forty-eight hours, 
at 68° F., from the time of inoculation, a whitish turbidity 



94 



STUB: CHOLERA ASIATICA AND CHOLERA NOSTRAS. 



[8. Y. Med. Jodr., 



will start, in the immediate neighborhood of which the gela- 
tin will become liquefied ; but tins process is so slight that 
only a very fine capillary tube will be the result, which 
becomes a little wider toward the surface. The top of this 
tube is generally below the level of the solid gelatin, and 
upon the top of the tube we generally see an air-bubble. 
The liquefied gelatin remains clear, and only upon a few 
places do a few whitish masses appear. After four to six 
days the gelatin will be sufficiently liquefied to reach the 
walls of the test-tube. The spirillum of cholera nostras, 
however, is characterized by its very energetic liquefying 
action upon gelatin. 

"Within twenty-four hours it has formed a wide tube 
filled with a diffuse opalescent fluid, and the surface of this 
tube extends to the walls of the test-tube. The lower end 
of the tube is widened out sack-like. I may add also that 
the cholera spirillum does not grow upon potatoes at a tem- 
perature less than 86° to 88° F., and from 98£° to 99£° F. 
it forms a dark-brown paste upon the surface. The spi- 
rillum of cholera nostras grows beautifully upon potatoes- at 
64*5° F., and forms a yellowish-gray covering. 

However, before I proceed to make a cultivation of the 
bacilli to be found in the alvine evacuations, I first make 
an attempt to relieve the patient by a hypodermic injec- 
tion of sulphate of morphine and atropine. I order fric- 
tions with soap liniment, chloroform, and laudanum to the 
body ; also sinapisms alternately applied to the extremities 
and epigastrium, hot flat-irons or bottles filled with hot 
water to the soles of the feet, and try to administer a good 
dose of 10 to 15 grains of calomel internally, and order the 
same to be continued in small doses of about two grains 
every two hours. 

I certainly shall not give bismuth, either the subcarbo- 
nate or the subnitrate, because I wish to avoid everything 
which tends to make the contents of the stomach and 
alimentary canal more alkaline. I do not expect anything 
from the calomel except from its property as a mercurial to 
destroy the cholera germ by acting as a poison directly upon 
the latter; and perfectly agree with the views of Dr. Pallen, 
of New York, who published the same in the " Medical Rec- 
ord" of March 7th, and who contended that during cholera 
the stomach and alimentary canal were not capable of assimi- 
lating any medicine whatsoever. For this very reason I 
shall also continue the hypodermic injections at proper 
intervals, and in accordance with the urgency of the case. 
Later on, when the condition of the patient requires it, I 
shall also administer brandy hypodermically. 

But, gentlemen, I shall also remember the results of the 
treatment of Professor Cantani, of Naples, who, during the 
last epidemic, resorted to acidulated enteroclysmata of a 
temperature from 103° to 104° F. According to Koch, one 
part of carbolic acid to 400 parts of water is sufficient to 
prevent the increase of the cholera bacilli, and, although we 
should not be justified in administering such a clysraa to a 
healthy person, I believe that, in case of cholera where all 
the powers of absorption by the intestinal canal were sus- 
pended, we might perhaps be able to resort to this propor- 
tion with benefit to the patient. Although Professor Ar- 
rnanni, of Italy, has found the microbes principally in the 



colon and caecum, and a number of cases have been treated 
with simple "medicated enemas with benefit, in severe cases, 
where the inroad of the microbe extends higher up, it will 
be necessary to resort to an enteroclysma which will reach 
beyond the ileo-caecal valve. 

Of all substances, however, which prevent the reproduc- 
tion of the cholera bacillus, the bichloride of mercury stands 
foremost. Oil of peppermint has this property in the propor- 
tion of 1 to 2,000, sulphate of copper 1 to 2,500, quinine 1 
to 5,000, and the bichloride of mercury 1 to 100,000. For 
this reason I would try the sublimate in combination with 
hydrochloric acid : first as an ordinary enema, and later on, 
if I found the disease make progress and the case become 
desperate, as an enteroclysma. If, however, I were able 
to dust the whole of the alimentary canal over with calomel 
in the same manner as we sprinkle iodoform over an ulcer- 
ated surface, I think I should prefer the latter method to 
kill the microbe. 

I am not aware that the sublimate has been tried in the 
manner proposed by me, and I certainly would abstain from 
its use in the beginning of the disease and before the faculty 
of absorption had ceased. The algid stage, I think, would 
be the proper time to begin with, and previous to it I should 
confine myself simply to copious enemas' of hot water acidu- 
lated with hydrochloric acid, and administer the latter also by 
the mouth in the form of an iced lemonade to relieve thirst. 

Whether an occasional enema or an enteroclysma of hy- 
drochlorate of quinine, dissolved in hot water and acidulated 
with hydrochloric acid, would be desirable, I think a mat- 
ter worthy of consideration. 

Gentlemen, we put a typhus-fever patient into an iced 
bath with the view of reducing his temperature. Would it 
be unscientific and unpractical to put a cholera patient into a 
•permanent hot bath with a temperature, say, of 104° or over 
to increase his temperature ?• Koch considers the manner in 
which the cholera bacillus produces certain changes in the 
system a poisoning process, and states that in his opinion 
the poisonous properties of the bacillus act with paralyzing 
influence upon the circulatory apparatus, and, although this 
seems to be only theoretical so far, it would explain the fact 
that hot baths have proved of benefit in cholera. I must 
also allude to the transfusion of salt water into the venous 
system as advocated by Dr. Kronecker, who also gives a 
description of an apparatus to be used for the purpose, and 
who condemns the practice of intra-abdominal and subcu- 
taneous injections, frequently resorted to during the last 
epidemic in Italy, on account of the impossibility of regu- 
lating the time when the injected fluids may enter the cir- 
culation. 

During the same epidemic the following treatment was 
adopted. Cantani, Paoluzi, and particularly Dr. Yitone, 
speak of the excellent results of a clysma composed of 

Inf. flor. camomill (38° C.) 2 litres; 

Acid, tannic 3,0-6,0 grammes; 

Gumm. arab 30,0-50,0 " 

Laudanum 30,0-50,0 " 

which, freely administered, caused intermissions of from six 
to twelve hours. With all internal remedies for the pur- 



July 25, 1885.] 



STUB: CHOLERA ASIA TWA AND CHOLERA NOSTRAS. 



95 



pose of disinfecting no result has been obtained. But all 
Italian authorities agree that subcutaneous injections of 
morphine have been of benefit. Of special benefit, how- 
ever, have been irrigations per rectum of carbolic acid, sub- 
limat, iron sulphate, and quinine. 

In the algid stage Cantani has resorted, with considera- 
ble benefit, to subcutaneous injections of salt water of the 
temperature of about 100° F. and in the proportion of thirty- 
four ounces of water, sixty grains of table-salt, and forty-five 
grains of carbonate of sodium. 

He observed in the severest cases an abatement of all 
the urgent symptoms within a few minutes after this enema 
had been given. During the stage of asphyxia, subcutane- 
ous injections of ethereal tincture of valerian, ether, and 
sulphate of caffeine were used. 

The Italians also speak highly of hot baths and of the 
inhalations of oxygen. Cantani especially mentions that 
during convalescence we must be careful to avoid milk and 
beef-tea or meat broths of any kind, because the comma ba- 
cillus is apt to grow in those media and a relapse may be 
the consequence. But between the two he would prefer 
meat broths, because he found that milk never did agree 
with his patients. His meat broths he acidulated with 
hydrochloric or lactic acid. In case, after the strength of 
the patient has returned, vomiting persists in consequence 
of hyperesthesia of the stomach, he recommends ether and 
chlorodyne, or cherry-laurel water with morphine or bella- 
donna. 

Dr. Dornbluth, of Rostock, recommends calomel to be 
given as I have recommended before, and particularly in 
the typhoid stage he calls attention to resorcin and cotoin. 
He speaks highly also of subcutaneous or intravenous injec- 
tions of salt water, to overcome the thickening of the blood. 
During the epidemic in Toulon the treatment of the so- 
called cholera diarrhoea consisted of 



R, ^Ether 1,0; 

Tinct. opii gtt. xv-xx ; 

Ext. kramerhe 1 ,0 ; 

Syr. cort. aurant 30,0 ; 

Aq. melissa? 120,0. 



Against the vomiting, every quarter of an hour a tcaspoonful 
of Chartreuse, sometimes bismuth and opium. 

In more serious cases this treatment is combined with 
injections of warm wine and laudanum, carbonic-acid water 
cooled on ice, and, against profuse diarrhoea, water saturated 
with oxygen gas, to which I personally beg leave to object, 
as the cholera bacillus belongs to the species of aerobe bac- 
teria and requires oxygen to develop. Frictions with ol. 
terebinthime, opodeldoc, and chloroform are used. Hypo- 
dermic injections of morphine in the epigastric region are 
particularly mentioned by Dr. Cuneo, physician-in-chief of 
the navy of France, who has found great benefit from the 
hypodermic injection of half a centigramme of hydro- 
chlorate of morphine with one quarter of a milligramme of 
atropine. Spasm of the muscles of the lower extremities he 
has treated successfully with hypodermic injections of ether. 

During the stage of asphyxia, injections of ether pro- 
longed life for a few hours in a few cases, but subcutaneous 



injections of atropine sulphate, first one half a milligramme 
and afterward one milligramme, from four to five times in 
twenty-four hours, caused a rise of temperature of 2° in one 
case. 

He also professes to have saved six patients with inhala- 
tions of pure oxygen by means of a mask and a tube, the 
latter introduced into the nares. In those cases where cold- 
ness and cyanosis did not form the prominent symptoms, this 
treatment, which he, by the way, repeated every half-hour, 
and continued for two minutes each time, gave no results. 

The question of prophylaxis requires consideration in 
this paper, and I would like to call attention to the remarks 
made at the meeting of the Imperial Board at Berlin, July 
24, 1884, by Dr. Leyden, that a certain immunity exists 
against a second attack of cholera, although this immunity 
does not seem to be absolute, and it is well authenticated 
that persons have been attacked by cholera in one epidemic 
and died during a second attack in another epidemic. 
More rare, however, is the fact that a person has been at- 
tacked more than once during one epidemic, although Dr. 
Wievioroevski quotes the case of a patient who was taken 
sick August 13th, left the hospital well on the 20th, and 
was taken sick again with cholera on the 5th of September, 
and died.. Dr. Koch, however, thinks that such cases must 
be very rare, and seems to be of the opinion that one attack 
secures the person against a second attack during the same 
epidemic in most cases. Perhaps being impressed with the 
same views, a Spanish physician inoculates his clients with 
the comma bacillus, as I have read in a daily paper. It is 
remarkable, however, that the medical papers are silent upon 
the subject, or that they only give short notices of Dr. Fer- 
ran's investigations.* If Dr. Ferran's microbes are identical 
with Koch's bacillus, it would appear impossible to inoculate 
them into the blood with any chance of success, because the 
circulatory system does not seem to be the home of this 
parasite. In none of the post-mortem examinations Koch 
has made could lie detect this parasite outside of the ali- 
mentary canal, and only very rarely in the contents of the 
stomach. If found in the latter, it has been only in cases 
where a process of regurgitation had caused faeces to enter 
the stomach. The blood and other fluids of the body are 
not invaded by the bacillus, and not a single case is on 
record where infection has taken place from a post-mortem 
examination. Whether Koch's comma bacillus assumes 
different properties if cultivated and recultivated upon dif- 
ferent nutritive media, is a question which later investi- 
gations will certainly solve. If I may venture upon an 
opinion at all in this matter, it is that, if artificially culti- 
vated bacilli have the property of causing immunity from a 
severe attack of cholera, they should be introduced into the 
intestine and not into the circulation. The question natu- 
rally forces itself upon me, Is this microbe of Dr. Ferran's 
actually identical with Dr. Koch's bacillus, or is it the same 
Dr. Emmerich, of Munich, has discovered in the blood and 
in the tissues of the whole body of persons who died of 
cholera ? 

* Only the "Deutsche medicinische Woehonschrift," of Berlin, April 
20, 1885, speaks of the fantastic views of Dr. Fenan in reference to 
his inoculation of the bacillus. 



96 



STUB: CHOLERA ASIATIC A AND CHOLERA NOSTRAS. 



[N. Y. Med. Jocb., 



Dr. Emmerich also cultivated his bacterium, and inocu- 
lated various animals with the same. They all died, but 
post-mortem examinations seem to have revealed the fact 
that Peyer's patches were ulcerated, which led critics to 
assume that those animals did not die of cholera but of a 
septic poison. Koch has made about one hundred post- 
mortem examinations in Egypt, India, and France, and in 
all cases the result has been the following. He divides 
the results of his investigations into three different varieties. 
First, he mentions cases where the lower part of the ileum 
and caecum, and particularly above the ileo-cajcal valve, had 
assumed a dark-brown, reddish color, the mucous membrane 
being studded upon the surface with hemorrhagic exuda- 
tion. In a few cases he found diphtheritic patches, and 
the membrane almost necrotic. In accordance with this, 
the contents of the bowels were not of rice-water appear- 
ance, but a bloody, stinking fluid. In the second class 
of cases the redness was less marked, being only by spots, 
and in some cases only the edges of the follicles and 
Peyer's patches were reddened. The last form he considers 
to be particularly characteristic; it does not appear in any 
other affection of the alimentary canal, and seems to be 
peculiar to cholera. 

In comparatively few cases did he find the mucous 
membrane little changed ; it looked swollen and less trans- 
parent in the upper layers, the solitary follicles and Peyer's 
patches were more prominent, the whole of the mucous 
membrane was of a light rose color, but in no case was 
there capillary bleeding. 

In those cases which constitute the third class the con- 
tents of the bowels were colorless — not always like rice- 
water, but more like water which had been mixed with 
flour. Only a few cases came to his notice where the 
contents of the bowel were a watery mucus ; the reddened 
edges surrounding Peyer's patches contained the most of 
the comma bacilli. All the animals which died after be- 
ing injected with the virus presented the same symptoms 
and the same post-mortem appearances. Numerous experi- 
ments to this effect have recently been made by Koch, 
Klob, Nicati and Rietsch, Cantani, and others, and all to the 
same effect. In addition to the foregoing, I may state that 
the spleen in cholera cases, and in animals which died after 
being injected with the cholera bacillus of Koch, has al- 
ways been found atrophied. It seems that the spleen of 
animals inoculated with the bacterium of Emmerich was 
found to be the reverse. In my opinion, all the experiments 
made upon animals must be accepted with caution as re- 
gards their bearing upon the cholera-germ question, because 
no cases are on record in which an animal ever has taken 
the cholera during any of the great epidemics in India and 
in Europe. They seem to enjoy an immunity from this 
disease, and whether we are able to produce it artificially or 
not is a question not yet solved to my satisfaction. 

After this digression, I beg leave to mention one prophy- 
lactic which enjoys a reputation with some medical men 
up to the present time. It is the sulphate of copper, to be 
taken daily in very minute doses, during the whole course 
of an epidemic. The French particularly seem to have 
been impressed with this belief, and Burq, the father of 



metallotherapy, recommended it in 1857. French medi- 
cal papers also quoted instances where large bodies of 
troops marched through cholera districts and enjoyed im- 
munity from the disease, which was explained by the fact 
that they had been constantly dosed with the copper during 
the time they traveled through the infected locality. Dr. 
Garrigues, formerly of this city, stated to me that he at- 
tended a hospital with six hundred cholera patients, during 
the year 1864, at Copenhagen; that he took daily small 
doses of the copper, and did not get the cholera, but, as he 
remarked, other physicians in the same hospital, who also 
did not get the cholera, did not take the copper. 

Gentlemen, I think the best prophylactic will be to 
avoid everything that tends to derange our digestive organs, 
and which may give rise to an intestinal or gastric catarrh. 
The healthy gastric juice will certainly kill the cholera 
germ; but an alkaline condition of the contents of the 
stomach will be the means of its passing into the intestinal 
canal, and then the mischief begins. I would, perhaps, rec- 
ommend taking small quantities of hydrochloric acid every 
time we drink water. I should certainly prefer distilled 
or, at least, boiled water to the ordinary drinking-water. 
Although the bacillus can not live longer than two days 
and can not reproduce itself in pure water, the ordinary 
drinking-water may contain enough of the germ to infect 
us. The same with milk ; it should never be used unless it 
has been boiled first ; then milk in particular forms a good 
nutritive medium for the microbe. 

In the rooms of the sick I would strictly enforce the 
rule that nobody should be allowed to eat or drink except 
the patient, and I would urge upon the attendants to wash 
their hands with a solution of bichloride before taking food. 
I would not trust to any other disinfectants in the rooms of 
the sick, unless later researches should give us practical proof 
that some of the articles of commerce now in the market, 
and highly extolled as disinfectants, will stand the scientific 
test against cholera germs. It seems that all acids are not- 
destructive to the cholera germ, as is proved by the fact that 
it will grow upon freshly cut potatoes, and such a fresh cut 
has an acid reaction. For this reason I would advise to 
abstain from the use of fruits, apples in particular, because, 
besides that they have the faculty of rendering the contents 
of the stomach alkaline, they may also be the direct means 
of introducing the bacillus into the stomach. In using dis- 
infectants we should strictly avoid those which retard putre- 
faction, for it has been amply proved that the bacillus of 
putrefaction is the deadliest enemy of the comma bacillus, 
and that wherever the former appears the latter disappears. 
To put sulphate of iron into a cesspool containing excre- 
ments of human beings during a cholera epidemic would 
prepare a good nutritive element for the germ. I would 
like to call the special attention of our Board of Health to 
the cesspools of our public resorts, particularly to those of 
Coney Island. If no proper care is exercised in disinfect- 
ing the same, they may be the cause of much suffering. 
Bichloride in liberal quantities, often applied, will be the 
only means, in my opinion. Not those means which only 
deodorize come into consideration in this momentous ques- 
tion, but those disinfectants which kill the germs of the 



July 25, 1885.] 



STUB: CHOLERA ASIATIC A AND CHOLERA NOSTRAS. 



97 



disease. The best of all means of killing the cholera bacil- 
lus is dry heat. If it is subjected to a drying process, it 
will die within a few hours. For this reason I mentioned 
before that I did not think the importation of rags from 
Europe could import the disease also, because all rags, 
before they are shipped for commerce, are subjected to a 
drying process. For the reason that dry heat kills the 
germ, I would recommend stopping the sprinkling of the 
streets during an epidemic of cholera, and I would also 
recommend that all the bed-clothing of cholera patients, 
and all the personal wearing apparel used during their ill- 
ness, be subjected to a process of dry heat. If all the ex- 
crements could be destroyed by fire, it would be better 
still ; but, as such a process would be difficult or impos- 
sible to accomplish, let us boil, at least, the clothes in a 
solution of bichloride, and then subject them to a process 
of drying in a hot stove, and, if they burn, it will be all 
the better. No wet clothing of cholera patients should be 
allowed to hang out in the yards or upon the roofs of houses 
to dry, there is such a possibility of a strong draught of 
air taking up the germ and carrying it to a soil where it 
may grow and increase. Gentlemen, you will remember the 
appropriate remarks made by the medical officer of the 
navy who visited our last meeting. You will remember 
that he told us that during a time when cholera was raging 
in India a United States man-of-war was lying in the Ganges 
in midstream, and none of the officers or crew took the 
cholera. Why did that happen ? First, the proverbial 
cleanliness on board of a United States man-of-war, and, 
second — and may be, perhaps, first — because they drank 
only distilled water. 

Although I told you that the comma bacillus could live 
only a few hours in w r ater, and did not multiply there, it 
may grow upon the soil of the banks of a river, provided 
the soil happens to have some of the elements necessary for 
its reproduction. The stream of water may carry the germ 
along, and by that means become the cause of the disease 
— one reason more why we should drink only distilled or 
boiled water during those times, and why we should not 
sprinkle the streets. I beg leave to mention that Dr. Koch 
spoke to the Medical Society of Marseilles, and stated that, 
in his opinion, chloride of lime must not be relied upon as 
a means for disinfection. He advises keeping a five-per- 
cent, solution of cai'bolic acid in all vessels used in the room 
of a cholera patient. The best means of destroying the germ 
he considers hot steam, which must be used with an appa- 
ratus from which a jet of steam issues of a temperature of 
100° C. Such a system may well be carried out in hospitals, 
etc., but in private dwellings, tenement-houses, etc., it will 
be impracticable, and I think boiling with a strong solu- 
tion of bichloride, and afterward drying in a hot stove, will 
answer our purpose in private practice. The solution of 
sublimate which he recommends as wash-water for the hands 
of nurses and physicians who attend cholera patients should 
be of the strength of 1 to 1,000. Koch also urges to avoid 
drinking water unless it has been previously boiled, and he 
himself, during his stay at Marseilles, drank only mineral 
waters, and always washed his hands in a solution of subli- 
mate before he took his meals. He strongly urges the 



washing of all cooking utensils, glasses, etc., with boiling 
water, and is of the opinion that, although beer in all proba- 
bility does not contain the microbes, the water in which the 
glasses have been washed may do so, and thus cause in- 
fection. Gentlemen, I am of the opinion that our system 
of sewerage, our water supplies, etc., and the general sani- 
tary condition of this city, thanks to the efforts of the 
Board of Health, are such that we may consider ourselves 
well prepared to meet the enemy if he attempts an inva- 
sion. 

We hear of unclean streets, and in some parts of the 
city an improvement would be desirable, but, on the whole, 
we may compare well with such cities as Naples, Toulon, 
or Marseilles. Although it may be comfortable to con- 
template this condition of affairs, vigilance in sanitary mat- 
ters must not cease, and we, as physicians, should be will- 
ing to lend a helping hand to the efforts of the Board of 
Health to suppress an epidemic by reporting every suspect- 
ed case as soon as it occurs. I contend that private inter- 
est must not be taken into consideration as long as the 
public welfare is at stake. 

I have not mentioned in this paper the report of the 
English commission which was sent to India to investigate 
the cholera. The exact words which Dr. Klein used in his 
report, March 24th, before the Royal Medical and Chirurgi- 
cal Society of London, copied from the London " Lancet " 
into the " Deutsche medicinische Wochenschrift," April 
16, 1885, are the following: "Comma bacilli of various 
species have been discovered in other diseases of the ali- 
mentary canal, in the fluid of the mouth of normal per- 
sons (Lewis), and in old cheese (Deneke). The comma 
bacilli found by Finkler and Prior in cholera nostras differ 
in mode of growth from Koch's comma bacilli of cholera ; 
so do those found in diarrhoea due to other causes ; but 
those of the fluid of the mouth are identical with Koch's 
comma bacilli in many respects." 

He admits, consequently, that they are not identical in 
all respects, and I may refer you to my former remarks that 
Dr. Lewis's bacilli do not grow upon alkaline nutritive gela- 
tin. I would recommend to all those of you gentlemen 
who wish to be informed upon the subject of the cholera 
bacillus to read the reports to the Scientific Grants Com- 
mittee of the British Medical Association, by W. Watson 
Cheyne, Assistant Surgeon to King's College Hospital, etc., 
and Research Scholar of the British Medical Association, as 
published in the "British Medical Journal." One of the ar- 
ticles published in the "Journal " of May 2, 1882, I have seen 
throusrh the kindness of Dr. Hunt, and I found it to be such 
a lucid and true expose of Koch's discoveries that 1 beg 
leave to mention it here. It gives all the illustrations, 
partly after Koch, and in a great measure after Mr. Cheyne's 
own investigations, and mentions also the later highly in- 
teresting researches of a Mr. E. M. Nelson in reference to 
the discovery of the flagella of the bacillus, before unknown 
to me. I would not have mentioned Dr. Klein's report in 
this paper, because I considered the matter as settled, had 
not an allusion to it been made at our last meeting, and if 
the president of the Medical and Chirurgical Faeultj of 
Maryland, at the annual session, May 12th, as reported by 



98 



MILLS: RIOQS'S DISEASE. 



[N. Y. Med. Jode., 



the "Medical Record," May 10th, had not stated in his 
opening address, " Origin and Diffusion of Cholera," that 
he " did not consider the parasitic origin of the disease 
proved, because Kocli had not succeeded in producing the 
disease by injecting the comma bacilli, and Lewis had dem- 
onstrated the presence of bacilli in the human system under 
other circumstances." But not alone Koch, but Klob, 
Rietsch, Xicati, and others have successfully injected the 
comma bacillus into the intestines of animals, as already 
stated before, and Lewis's bacillus is certainly not identical 
with Koch's. Gentlemen, if a physician has a suspected 
case of kidney disease, he is expected to test the urine 
for albumin, and examine into the percentage of urea and 
look for casts, etc. ; but, when it is necessary to make a quan- 
titative analysis of the urine, lie will be obliged to get a 
specialist to attend to the matter ; for, even if he has the 
necessary knowledge and apparatus to do so, he has not the 
time. If a hospital surgeon removes a tumor from a patient 
he turns the specimen over to a pathologist for microscopi- 
cal examination, and I think it will be the same with the 
examinations of the excrements of suspected cholera cases. 
We, as practical physicians, will be able to make the primary 
examinations by cultivation and with the microscope; but 
when it comes to further scientific researches into the mat- 
ter, there our duty ends, and also our ability. A constant, 
untiring observation, together witli the minutest attention 
to details, is necessary to carry out the investigations, and 
those of us who undertake to work further upon this tield, 
with the hope of adding something new to the general 
knowledge, will be sorry to find that they worked in vain 
because they have no time for such researches. We have to 
content ourselves with utilizing the discoveries made by 
those who make it their sole study. If the German Gov- 
ernment, however, thinks the matter of sufficient practical 
importance to detail by turns all the medical officers of 
the army to take a course in the laboratories of the board 
of health at Berlin, to enable the army physicians to make 
the necessary investigations for diagnostic purposes, I think 
it will not be out of the way if I herewith respectfully 
suggest that our Board of Health detail one of its mem- 
bers to take a course at the lately established laboratory of 
the Bellevue Hospital Medical College, for the purpose of 
familiarizing himself with the technical methods of making- 
such investigations, and if, with a little financial aid from 
the city, the Board of Health could afterward establish a 
laboratory for biological researches, it would materially fur- 
ther rational sanitary purposes. 



KIGGS'S DISEASE. 

By G. A. MILLS. 

At a meeting of the Connecticut Valley Dental Asso- 
ciation, about eighteen years ago, at Northampton, Mass., 
John M. Riggs, M. D., of Hartford, Conn., was invited to 
make a proclamation (associated with a clinic) of his views 
concerning a diseased condition of the gums and the sockets 
of the teeth which often causes the loosening and falling out 
of the same. Hp to this time nothing had appeared in the 



literature of dentistry except that which classed this dis- 
order among the incurables, and it was spoken of as the 
resultof senility; hence the common remark among people, 
" My father's and mother's teeth all dropped out, and it is 
only a matter of time with me." The removal of tartar as 
an external deposit upon the teeth was classed simply as an 
operation of scaling. This -operation only recognized the 
foreign matter that could be seen. Dr. Riggs, in announc- 
ing his original views — while he gave it as his opinion that 
the deposits of tartar were the cause of the disorder under 
consideration — stated that his observation and experience 
matured the knowledge that there was a decided progressive 
inflammation existing under the gums and wasting both the 
hard and soft tissues, so that their attachments with the roots 
were gradually being destroyed. His knowledge of surgical 
principles suggested a practical application to these diseased 
localities, and he proceeded to the removal of all foreign sub- 
stances from the roots of teeth, and the trimming of the ne- 
crosed edge of the alveolus to the life-line, leaving nature to 
restore to a normal condition. Dr. Riggs's view naturally 
excited a variety of comment — some expressing disbelief, and 
others accepting his novel ideas and statements. Not a few 
denied the existence of a necrosed edge of the alveolus. Dr. 
Riggs had devised a set of instruments well adapted for the 
treatment of this disorder — and these were unique and new, 
yet there was an effort on the part of a very few to dispute 
his claim to this invention ; this did not prove a success. 
This body (the Connecticut Valley Dental Association) sub- 
sequently passed a resolution giving credit to Dr. Riggs for 
originality relative to the new pathology of the disorder 
now termed Riggs's disease, and so named at about that 
time in honor of Dr. Riggs. I have previously remarked 
that nothing of the doctor's view-s had ever been published 
so far as known. But — having become personally much in- 
terested in this disease, and in the discussion of it, and 
also finding my position regarding it misunderstood by sev- 
eral dentists — I was led to prepare a series of articles (six), 
which were published in the " Dental Cosmos " during the 
years 1870 and 1877, under the title of " What I know- 
about Riggs's Disease," in one of which articles I challenged 
the record of views corresponding to Dr. Riggs's. Since then 
not a word has come from any source to show that he is 
antedated in the matter. I may add that a confirmation of 
his views and their acceptance by many members of the 
dental profession have gradually taken place. I am glad 
to say that to-day it is the most prominent subject for con- 
sideration before dentists generally. Only a limited num- 
ber, however, have come to a correct understanding of what 
is required and how to meet the requirements. These few 
are demonstrating a successful treatment of the disorder. 
At this point of my article it seems advisable to introduce 
a feature which I shall elaborate later on ; it is in reference 
to the technical term by which this disorder is now known 
— viz., pericementitis, substituted for the term well known by 
medical men — dental periostitis — meaning inflammation of 
the dental periosteum. This term (pericementitis) origi- 
nated in the laboratory of Charles Heitzman, M. D., of New 
York city, during the late investigations made there by den- 
tists under his instruction. The general subject of perice- 



July 25, 1885.] 



MILLS: RIGGS'S DISEASE. 



99 



mentitis it is not my design to discuss here, but it is neces- 
sary to make the distinction clear between Riggs's disease 
and general pericementitis. Riggs's disease is a peculiar 
phase of pericementitis ; it may exist to the final loss of all 
the teeth, without a sign of any other phase of this dis- 
order. 

As the nature of this disease is so plainly embodied in 
my brief history of the matter which includes its pathology, 
it would seem that my readers need not be ignorant of its 
main features ; therefore I pass to consider the diagnosis. 

To diagnosticate an incipient case, or first manifestation, 
as it is often seen in the mouths of children (even at a very 
early age) : The simplest form of the disease may often be 
seen at the peripheral part of the festoon of the gum-tissue 
indicated by a congested appearance; by lifting this gum 
with a delicate instrument, there will be seen a little seed- 
like granule of calcific substance. Another case might show 
a deep red and raw-looking, elongated appearance of the 
gum-tissue about the necks of the teeth, and with or with- 
out any deposit; there may be also a looseness of the gum 
about the .teeth, which causes quite a pocket. This latter 
condition is often a sequela of exanthematous disorders. 
The gums are often extremely sensitive to the touch. In 
the various cases we find general congestion, easy haemor- 
rhage, pale and bloodless gums, a decidedly anaemic and 
frequently pimpled surface of the gums — the latter appear- 
ance in adults. Not uncommonly a first warning to the 
patient (adult) will be pain or tenderness about the tooth or 
teeth, and an examination will not reveal any decay, death 
of pulp (commonly called nerve), or evidence of inflamma- 
tion of pulp. This is what I shall term a subtle manifesta- 
tion, for it has been believed there could be no inflamma- 
tion of the dental membrane without a disturbance of the 
pulp. Th is is now proved to be untrue, for abscesses do 
occur while the pulp remains normal. In a large propor- 
tion of cases there will be, on light pressure, a flow of pus 
from under the gums, and oftentimes it is a copious dis- 
charge. This may be general, or it may be confined to a 
single tooth. Looseness of one or more of the teeth may 
be observed ; also malposition, and this commonly after an 
occluding tooth is lost. I have given in detail enough of the 
manifestations to lead one even superficially familiar with 
unhealthy conditions to the diagnosis. It will be observed 
that I have omitted other conditions of disease that are 
manifested in the mouth, associated with the teeth and 
allied structures — viz.: syphilis, salivation, and scurvy. 
While in some instances these may be separated from the 
disorder in question, yet they are sometimes complications. 
I will mention another marked diagnostic feature associated 
always with an active stage of the disorder, and that is 
the odor which is distinctly noticeable to one familiar with 
Riggs's disease. There are other local manifestations that 
are, without doubt, largely influenced by the disease, but are 
commonly classed as expressions of constitutional debility, 
and still they may be wholly the result of the disorder un- 
der definition. This is proved by the arresting of the dis- 
ease when the disabilities referred to are removed. Reces- 
sion of gum-tissue is often seen, and no apparent inflamma- 
tory condition. While this is a peculiar phase, I maintain 



it is the same disorder. My term for it is atrophy of the 
gum-tissue — erosion of the tooth-structure, causing grooves 
across and around the necks of the teeth, not infrequently 
taking a serpentine direction. This also is a manifestation 
of the same disorder, as it is arrested by the treatment which 
will now be described. 

Treatment. — As the nature of the disorder has proved 
to be novel, so will the treatment appear, as Dr. Riggs 
was the inventor of a set of instruments with which to 
perform the operations required in treating the disease. 
Each one is six inches in length, including the handle, 
which is of ebony and steel, octagonal and tapered ; the 
blades are seven eighths of an inch long, bent at an obtuse 
angle. The instruments are in two pairs, and there are 
two single ones. One pair has a knife edge and a safe 
edge ; the other pair has the same, but these are reversed 
in their bevels — made so for the purpose of working at a 
different angle of the mouth, and from the operator instead 
of toward him. The single ones are double knife-edged, 
and differing in thickness of blade. Perhaps no better 
idea can be given of the general form of the blades than to 
say they resemble the half of a snipe's bill, the long, ovoid 
point being particularly adapted to ferreting out the intri. 
cate and deep-seated disordered parts of the hard and soft 
tissues about the roots of the teeth. In their dimensions 
they may seem ponderous to a novice, but in the hands of 
an expert no instrument can be more efficiently" and deli- 
cately used. It must now be seen, by the description and 
location of Riggs's disease, that most of the operation is 
under the gum-tissue and out of sight, so that necessarily 
to know when the operation is complete at a given point 
can only be accomplished by an acquired and acute sense of 
touch. It may be said that the Riggs treatment has in- 
stituted a distinct and systematic mode of arresting the 
disease. Rightly understood and rightly practiced, I re- 
gard this treatment as the most efficient in dental surgery. 
The severity of the cases differs according to constitutional 
conditions, and, if the dentist is the doctor, he will know 
whether the patient can be wisely aided by constitutional 
treatment. The prognosis must be based upon the condi- 
tions as they appear in each case. 

From an extensive experience within the last ten years 
in the treatment of a large number of cases, and the success 
attained, I am justified in saying that Riggs's disease can 
no longer be classed among the incurable ones. 

It is perfectly plain that this disease is not confined to 
any one period in life. Under the age of forty I have had 
numerous cases in the most active stages of progress — so 
noticeable that there was almost spontaneous haemorrhage of 
the gums, and such an excessive flow of pus that the service 
of napkins for absorbing was required in sleeping hours. 
These facts can be testified to by well-known physicians. 
As one impressed with the prevalence of Riggs's disease, 
and its destructive effect on the general health, I should be 
remiss in duty if I were silent, or neglected to call the ear- 
nest attention of medical men and the public to the grave 
facts, for they have had too little consideration. I would 
say emphatically that the most serious complications may 
arise, and the worst septic conditions may be threatened 



100 



BOOK NOTICES. 



[N. Y. Med. Jock., 



and encountered, from pure neglect. That one disorder 
not arrested calls others of a more serious nature into ex- 
istence is a well-known fact among medical men. 



Dooh Botites. 

A Text-Book of the Principles of Phytic*. By Alfred Daniell, 
M. A., Lecturer on Physics in the School of Medicine, Edin- 
burgh. London: Macmillan & Co., 1884. Pp. xx-653. 
[Price, $5.] 

This book is intended to be used in the preliminary medical 
course. The author justly lays stress in the preface upon the 
importance of the study of physics, and the close relation be- 
tween that branch and the department of experimental physi- 
ology. He states that it is his express purpose to avoid the in- 
troduction of " anything of the Dature of an unsolved riddle " 
into his work. But the reader will rind himself greatly in error 
if he regards this as an elementary treatise; a mere glance at 
the table of contents will assure him that he has not entered 
upon a course of light reading. The subject-matter is arranged 
in an ascending series. Beginning with introductory sections 
upon matter and its properties, we soon reach a solid chapter 
on "Kinematics," under which are included wave-motions and 
their demonstration by the aid of the higher mathematics. We 
prophesy that this will prove a tough morsel for the student, 
especially if he approaches it without a previous knowledge of 
the subject. 

Under " Kinetics" are included the familiar problems of the 
lever, inclined plane, screw, and wedge, with a paragraph on 
friction. " Attraction and Potential " and " Gravitation and 
the Pendulum " form the subjects of Chapters VII and VIII. 
Chapters IX, X, XI, and XII include "Matter," "Solids," 
"Liquids," and "Gases." With Chapter XIII we begin an ex- 
haustive consideration of " Heat," which is fully up to the latest 
theories. This is followed by " Sound," " Ether-waves " (as the 
author calls bis chapter upon light), and a concluding disserta- 
tion upon " Electricity and Magnetism." An exhaustive bibli- 
ography and an excellent index conclude one of the most 
scholarly works on physics that we have ever had the pleasure 
of perusing. We regret that we can not give a more extended 
notice of the book, but this is hardly permissible in a strictly 
medical journal. The reader who is prepared to give his close 
attention to every page is advised to look it over for himself. 
A superficial reading is worse than useless, for, as we before 
stated, this is not light literature. The criticism which we ven- 
ture to offer upon the volume as a whole is that it is entirely 
too advanced for the class for whom it is written. When we 
remember that the average medical student has not enjoyed a 
university education, we are compelled to believe that many of 
the pages of formula? and mathematical demonstrations will be 
quite beyond his grasp. As for the "general reader," whom 
the author also includes among his audience, it will be a very 
intelligent general reader indeed who profits by some of the 
more abstruse paragraphs. 

None of the familiar illustrations of physical apparatus have 
been introduced (we think unwisely), but their places have been 
supplied by numerous geometrical figures, often quite compli- 
cated. We do not wish to underrate the ability of our Ameri- 
can medical students, but we must confess that few of them 
would take pleasure in physics with such a text-book. A little 
less of mathematics and a little more of the practical applica- 
tion of theories would be highly desirable. 



The volume is a model of neatness and accuracy. The clear 
type, systematic arrangement — in fact, the tout ermenible — reflect 
great credit upon both author and publishers. 



Resocouto clinico del comparto Hpeciale per le malatlie cutanee 
delV Ospedale Maggiore di Milano, nel seiennio 1879-1884. 
Memoria del D. Ambkogio Bertarelli, medico aiutante. 
Milano: Tipografia Bortolotti di Dal Bono e C, 1885. Pp. 
vii-159. 

As its title indicates, this hook is a clinical report of theder- 
matological wards of the Ospedale Maggiore, of Milan, for the 
six years from 1879 to 1884 inclusive. We welcome it as an- 
other evidence of the intellectual activity of Italy, and as a voice 
from one of the largest hospitals in the world — one that was in 
operation before this country was discovered. 

Unlike many hospital reports, it is not a mere collection of 
statistics, but resembles rather a series of clinical lectures upon 
selected and more or less uncommon cases that have come under 
the writer's notice. About thirty diseases of the skin are treated 
of, illustrated by cases, and discussed in regard to their a'tiology, 
pathology, diagnosis, and treatment. The histories of many of 
the cases will well repay perusal, notably one of acute gangrene 
of the skin from softening of the brain. Much space is devoted 
to the consideration of eczema, lupus, and the parasitic dis- 
eases. 

The author is an enthusiastic disciple of Hebra. His views 
are, nevertheless, not limited by the horizon of the Vienna 
school, but are catholic in scope. We notice that in his thera- 
peutics he has given fair trial to the methods of the representa- 
tive men of all nations, and his deductions from these trials 
enhance the value of the work. The book is of value as an 
exposition of the state of dermatology in Italy at the present 
time, and we can only regret that Dr. Bertarelli has stopped 
short of giving us a complete treatise upon the diseases of the 
skin as seen in his country. 

BOOKS AND PAMPHLETS RECEIVED. 

Gout, and its Relations to Diseases of the Liver and Kid- 
neys. By Robson Roose, M. D., Fellow of the Royal College 
of Physicians in Edinburgh. London : H. K. Lewis, 1885. Pp. 

xii- 158. 

Manual of the Antiseptic Treatment of Wounds. For Stu- 
dents and Practitioners. By W. Watson Cheyne, M. B., 
F. R. C. S., Assistant Surgeon to King's College Hospital, etc. 
With Illustrations. New York: J. H. Vail & Co., 1885. Pp. 

xiii- 151. 

L'Annee medicale (septieme annee), 1884. Resume des 
progres realises dans les sciences medicales. Public sous la 
direction du Dr. Bourneville, Medicin de l'hospice de Bieetre, 
Redacteur en chef du "Progres medical." Paris: E. Plon, 
Nourrit et Cie., 1885. Pp. viii-409. 

Resoconto clinico del comparto speciale per le malattie cuta- 
nee dell' Ospedale Maggiore di Milano, nel seiennio 1879-1884. 
Memoria del D. Ambrogio Bertarelli, medico aiutante. Milano: 
Tipografia Bortolotti di Dal Bono e C, 1885. Pp. vii-159. 

A Manual for Hospital Nurses and Others engaged in at- 
tending on the Sick. By Edward J. Domville, L. R. C. P. Lond., 
etc. Fifth Edition. Philadelphia: P. Blakiston, Son & Co., 
1885. Pp. 96. [Price, 75c] 

The Pre-albuminuric Stage of Chronic Bright's Disease. By 
Charles W. Purdy, M. D., etc. Chicago : Clark & Longley, 1885. 
Pp. 35. 

Poliambulanza delle speciality medico-chirurgiche, premiata 
con medaglia d' argento all' Esposizione di Torino. II primo 
anno di vita (1 Ottobre, 1883—30 Settembre, 1884). 



July 25, 1885.] 



LEADING ARTICLES. 



101 



THE 

NEW YORK MEDICAL JOURNAL, 

A Weekly Review of Medicine. 

Published by Edited by 

D. Appleton & Co. Frank P. Poster, M. D. 

NEW YORK, SATURDAY, JULY 25, 1885. 



THE INTERNATIONAL MEDICAL CONGRESS. 

So far as our information goes at the time we go to press, 
the week has been comparatively barren of striking incidents 
growing out of the International Medical Congress difficulty. 
We have no knowledge of further concerted action in the way 
of resolutions of disapproval and withdrawal, but individuals 
have in a number of instances publicly declared themselves in 
accord with the action taken in Philadelphia, Boston, Balti- 
more, and Washington, and at the same time expressed their 
intention not to take part in the Congress as at present sought 
to be organized. It is worthy of note that not a few of these 
gentlemen are residents of the West. 

The inglorious part played by the New Orleans meeting of 
the American Medical Association continues to be the subject 
of comment. We have received a number of private commu- 
nications approving of the position we took in our issue of the 
11th inst., in which we explicitly fixed the responsibility for 
the present disgraceful state of affairs upon the association — 
not merely finding fault with the fortuitous indiscretion of the 
New Orleans meeting, but tracing the possibility of that action 
to the debased condition of the association itself. Many of our 
contemporaries are taking the same view of the matter, and 
some of them contain very pointed expressions. The "Medi- 
cal Record " says that we have shown the association to be "a 
useless and mischief-making body." It precedes this statement 
with the remark that we were " at first a little non-committal, 
not to say strabismic," in our views; but this we take in the 
Pickwickian sense which is occasionally to be discerned be- 
tween the "Record's" lines, and are content with its thor- 
ough approval of the position that it finally discovers us to 
hold. 

The " Medical News " says : " The men who are engaged in 
original research, and who are best known as those who are 
contributing to the honor and dignity of American medicine by 
their writings and teachings, are not usually active in medical 
politics or in the supervision of their medical brethren, nor are 
they given to log-rolling and striving for office. For the past ten 
years these men have been becoming dissatisfied with the tone 
of the American Medical Association, and, while many of them 
have not formally severed their connection with it, they have 
nevertbeless ceased to attend its meetings." 

The " Maryland Medical Journal " uses the most forcible 
language to express its condemnation of the American Medical 
Association, as will be seen by its editorial of last week, which 
we reproduce elsewhere in this issue. The " Canada Medical 
and Surgical Journal " alludes to the withdrawals, and adds : 
" When we ask why they take this serious step, we learn that 



tbey have, in the first place, a deep distrust of the American 
Medical Association as an organization which could satisfac- 
torily carry out such an undertaking." 

Speaking of the general subject, the " Medical Times and 
Gazette," of London, says: "There is a very unfortunate dis- 
cussion going on at present in professional circles in America, 
which, it is quite possible, may turn out disastrously for the 
International Medical Congress which it has been decided to 
hold at Washington in 1887. It will be remembered that a 
small Committee of the American Medical Association was 
nominated by the executive of the Copenhagen Congress, with 
full power to add to their number, and to act on behalf of their 
professional brethren. Carrying out their mission, they chose 
as colleagues twenty-eight leading American practitioners, espe- 
cially selected on account of their standing in the profession, 
and drew up the programme which has already been published. 
Subsequently, when the Committee reported to the meeting of 
the American Medical Association at New Orleans, exception 
was taken to their proceedings on the plea that they had ex- 
ceeded their powers, and had no commission to act on behalf of 
the association. The jealousies that had been roused among 
those who had been passed over in the co-optative selection 
were worked upon by two or three pushing wire-pullers, and, 
in the end, resolutions were passed, revising the work of the 
Committee, and substituting a Committee of thirty-eight men 
selected from the different States and Territories for those 
added to their number by the original Committee. At a subse- 
quent meeting, the results of which we are daily expecting to 
hear, the subject was again to come under consideration, and 
we learn that it was the intention of all the leading practition- 
ers in the States to withdraw from the Congress, if the decisions- 
of the original Committee were not treated with more respect. 
We sincerely hope that the profession in America will strenu- 
ously support their recognized leaders; otherwise they will 
make an exhibition of themselves to the world, and, besides im- 
periling the future success of those international gatherings 
which have hitherto been conducted with so much harmony, 
will distinctly lower the respect in which the profession is held 
throughout the world." 

MINOR PARAGRAPHS. 

"DANIEL'S TEXAS MEDICAL JOURNAL." 

" Daniel's Texas Medical Journal " is now, to use its own 
expression, launched. We lately took occasion to commend Dr. 
Daniel's undertaking, and he now reciprocates by mentioning 
this journal a number of times in his first issue. To be sure, 
much of what he puts forward as quotations from our columns 
never appeared in them, but we have grown quite accustomed 
to being misquoted and to having our meaning perverted. It 
seems that this journal was not the only one to notice Dr. Dan- 
iel's journal in advance of its appearance, for he quotes the fol- 
lowing — and we envy the state of mind that enables him to re- 
produce it with apparent satisfaction — from the "Denver Medi- 
cal Journal " : " Dr. F. E. Daniel, of Austin, Texas, sends us the 
prospectus of 'Daniel's Texas Medical Journal.' To those <>t' 
our readers who were lovers of the editorial writings of the 
much lamented Gaillard we commend Dr. Daniel as the coming 



102 



MINOR PA 



EAORAPHS. 



[N. Y. Mkd. Jocb., 



' Mephistopheles of medical journalism.' At least we will ven- 
ture to so christen the baby." We wonder if Dr. Daniel has 
ever read Faust, and we wonder also if the " Denver Medical 
Journal " realized with what sort of character it coupled the 
name of a man who was utterly free from guile. 



VIVISECTION IN ENGLAND. 

We regret to learn that Mr. Lawson Tait has again thought 
fit to cast the weight of his influence publicly in aid of the anti- 
vivisection mania in England. We do not question bis entire 
conscientiousness in the matter, and it is even conceivable that 
he might make a good argument in favor of the proposition 
"that vivisection is not only useless in solving riddles such as 
we have to deal with, but that it is absolutely misleading." A 
forcible argument could perhaps be made in support of that 
position, but certainly not one that would prove convincing to 
the present generation of medical men, who owe almost all that 
they possess of real physiological knowledge to the practice 
which Mr. Tait condemns. 



THE PROPOSED TEACHING OF HYGIE.VE AT WEST POINT. 

It seems to us that a most excellent suggestion has been 
made in the recent report of the Board of Visitors of the Mili- 
tary Academy, namely, that the officers of the medical corps od 
duty at the post should give lectures on hygiene to the senior 
class of cadets. Not only is it indisputable that a knowledge of 
the principles of hygiene by the line officers of the army is in 
the highest degree desirable, but it is also scarcely less certain 
that for the medical officers in question to devote a portion of 
their time to teaching those principles would be both agreeable 
and profitable to them as individuals and as officers. Moreover, 
in the course of a very few years the whole medical corps 
would find its routine duties much facilitated by the increased 
readiness with which officers in command of posts would grasp 
the purport and appreciate the importance of the hygienic 
measures recommended by the medical officers from time to 
time. We trust, therefore, that the board's suggestion will 
meet with favor at Washington. 



NEWS ITEMS, ETC. 

Infectious Diseases in New York.— We are indebted to 
the Sanitary Bureau of the Health Department for the following 
statement of cases and deaths reported during the two weeks 
ending July 21, 1885 : 



DISEASES. 


Week ending July 14. 


Week ending July 21, 


Cases. 


Deaths. 


Cases. 


Deaths. 


Tvphus 


1 


0 


1 


0 


Tvphoid fever 


9 


2 


10 


2 


Scarlet fever 


31 


9 


40 


14 


Cerebro-spinal meningitis .... 


4 


3 


4 


3 


Measles 


55 


10 


48 


8 




55 


24 


59 


23 




2 


1 


2 


0 



Small-pox is reported as prevailing in the town of Scotland, 
in Dakota, twenty-five cases having been discovered last Sun- 
day. 



Anthrax in Louisiana. — Anthrax is reported to be prevail- 
ing extensively among cattle in the region of New Iberia, La. 

The International Sanitary Conference and the Disin- 
fection of Rags. — One of the incidents in a controversy that 
has been going on for some months between certain sanitary 
officials and the importers of rags was the suggestion that a 
report of the proceedings of the recent International Sanitary 



Conference held in Rome, which appeared in a Philadelphia 
medical journal, contained an interpolation by the correspondent 
of the journal in question, in the following clause : '' Disinfection 
of merchandise and of the mails is unnecessary (steam under 
pressure is the only reliable agent for the disinfection of rags — 
les chiffons en gros).' 1 '' This suggestion having been urged in 
the "New York Times," the American delegate to the Confer- 
ence, Dr. George M. Sternberg, of the army, wrote to that 
paper denying the truth of the charge and affirming the accu- 
racy of the account given in the Philadelphia journal. The 
" Times " now returns to the matter and publishes the follow- 
ing remarkable statement: 11 A gentleman of this city, who is 
interested in the importation of paper stock, wrote to Dr. Koch, 
at Berlin, for definite information on this point, and yesterday 
he received a cablegram stating that no such words as those 
quoted in parentheses appear in the report of the committee." 

The American Laryngological Association.— At the re- 
cent annual meeting, held in Detroit, Dr. Wilhelm Meyer, the 
distinguished professor of laryngology in the University of Co- 
penhagen, and president of the combined laryngological and 
otological sections of the last International Medical Congress, 
was unanimously elected a corresponding fellow of the asso- 
ciation. Dr. H. Clinton McSherry, of Baltimore, and Dr. 
Charles H. Knight, of New York, were elected to active fel- 
lowship. 

Professor Tyndall's Gift to American Colleges.— The 

" British Medical Journal " states that the proceeds of Professor 
Tyndall's lectures in the United States in 1872, which, with the 
accumulated interest, now amount to $32,400, are to be divided 
equally between Columbia College, Harvard University, and the 
University of Pennsylvania. 

The Medico-Chirurgical College of Philadelphia. — We 

learn that Dr. F. Le Sieur Weir has severed his connection with 
the college. 

The Death of Dr. Thomas E. Burtsell, of New York, took 
place on Thursday of last week. The deceased was a graduate 
of the Medical Department of the University of the City of New 
York, in the class of 1844. 

The Death of Surgeon Joseph H. BilL of the Army, took 
place in Yonkers on Tuesday last. He was a native of Penn- 
sylvania, and was appointed first lieutenant and assistant sur- 
geon April 13, 1800. March 13. 1865, he received the brevet 
ranks of major and of lieutenant-colonel for faithful and meri- 
torious service during the war. April 13, 1865, he was com- 
missioned captain and assistant surgeon, and July 28, 1866, 
major and surgeon. His death is said to have been due to 
Bright's disease. 

Army Intelligence. — Official List of Changes in the Sta- 
tions and Duties of Officers serving in the Medical Department, 
United States Army, from July 12, 1885, to July 18, 1885: 
Voli.um, E. P., Lieutenant Colonel and Surgeon. To be relieved 
from duty in Department of the East on the expiration of his 
present leave of absence and to report to commanding gen- 
eral, Department of the Platte, for assignment to duty as 
attending surgeon at the headquarters of that department. 
S. O. 159, A. G. O., July 14, 1885. 
Middleton, J. V. D., Major and Surgeon. Leave of absence 

extended fifteen days. S. O. 159, A. G. O., July 14, 1885. 
Brown, J. M., Major and Surgeon, Captain Clarence Ewen, 
Assistant Surgeon, . Captain A. W. Taylor, Assistant Sur- 
geon, and First Lieutenant W. C. Borden, Assistant Surgeon. 
Ordered to prepare for field service. S. O. 64, Department 
of the Platte, July 9, 1885. 



July 25, 1885.] 



PROCEEDINGS OF SOCIETIES. 



103 



Gray, TV. W., Captain and Assistant Surgeon. Relieved from 
duty at Fort Barrancas, Fla., and ordered for duty at Fort 
Columbus, New York Harbor. S. 0. 147, Department of 
the East, July 13, 1885. 

Everts, Edward, First Lieutenant and Assistant Surgeon. Or- 
dered for duty as Post Surgeon, Fort McDermit, Nevada. S. 
(). 68, Department of California, July 11, 1885. 

Poliiemus, A. S., First Lieutenant and Assistant Surgeon. Or- 
dered for duty as Post Surgeon, Benicia Barracks, California. 
S. 0. 68, Department of California, July 11, 1885. 

Winn-e, C. K., Captain and Assistant Surgeon. Ordered for 
duty at Benicia Arsenal, California. S. O. 68, Department 
of California, July 11, 1885. 

Edie, G. L., and C. S. Black, First Lieutenants and Assistant 
Surgeons. Ordered for duty with troops en route to De- 
partment of Missouri. S. O. 78, Department of Texas, July 
10, 1885. 

Naval Intelligence. — Official List of Changes in the Medi- 
cal Corps of the United States Navy during the week ending 
July 18, 1885. 

Owens, Thomas, Assistant Surgeon. Granted sick leave for one 
month. July 14, 1885. 

Society Meetings for the Coming Week : 

Monday, July 27th : Boston Society for Medical Improvement. 
Tuesday, July 28th : Medical Society of the County of Putnam, 
N. Y. (annual). 

Wednesday, July 29th : Auburn, N. Y., City Medical Associa- 
tion; Gloucester County, N. J., Medical Society (quarterly); 
Berkshire District (Pittsfield) and Middlesex North District 
(Lowell), Mass., Medical Societies. 

Thursday, July 30th: Cumberland County, Me., Medical So- 
ciety (Portland). 



Proceedings of Soeutus. 



AMERICAN OPIITHALMOLOGICAL SOCIETY. 

Twenty-first Annual Session, held at the Pequot House, New 
London, Conn., Wednesday and Thursday, July 
15 and 16, 1885. 

Wednesday's Proceedings. — Morning Session. 

The meeting was called to order by the president, Dr. 
William F. Norris, of Philadelphia. 

Operation for the Removal of a Dislocated Crystalline 
Lens. — Dr. C. R. Agnew, of New York, related the steps of the 
operation as follows : The pupil was dilated, and the patient was 
then etherized and cocaine was applied. The eye was secured 
with fixation forceps. An instrument resembling a two-pronged 
fork, which was termed a bident, was introduced into the vitre- 
ous chamber behind the dislocated lens, pressing it forward. 
Section was then made and the lens removed. The eye was 
dressed with absorbent cotton and a black silk bandage. Anti- 
septic solutions were used, and a fonr-per-cent. solution of co- 
caine was applied twice a day. The eye recovered without any 
unpleasant symptoms. The speaker did not claim that all dis- 
located lenses should be removed, but this instrument facilitated 
the operation when it was required. 

Extraction of a Dislocated Lens.— Dr. David Webster, of 
New York, reported the case of a patient who received a blow 
on the right eye. This was immediately followed by loss of 
sight. Examination showed that the lens was dislocated. No 



treatment was recommended at that time. Some months later, 
pain suddenly appeared in the injured eye. The lens was found 
to be cataractous and incarcerated in the pupil. Cocaine was 
applied, but did not relieve the pain. Atropine relieved the 
pain. Later the lens became loose and was found in the vitre- 
ous. The tension was normal. It was decided to remove the 
lens. The bident was passed back of the lens, pressing it for- 
ward. The incision in the cornea was then made and the lens 
removed with a spoon. The eye was dressed with absorbent 
cotton, and recovered without complication. 

Dr. II. Knapp thought that in these cases there was not 
much difficulty in removing the lens, which could often be ac- 
complished with the loss of very little vitreous, but the danger 
came in afterward from inflammatory complications; and where 
the sight was lost he thought it better to enucleate the eye at 
once and tbus lessen the dangers of inflammation. 

Dr. Williams, of Cincinnati, agreed with Dr. Knapp that 
enucleation was the best procedure. 

Dr. Agnew thought that the bident might also be useful in 
the removal of foreign bodies from the interior of the eye. He 
did not acquiesce in the view that enucleation was a simple 
operation. He regarded it as a serious mutilation. 

Dr. C. H. Williams, of Boston, thought that there was an- 
other alternative than those mentioned, and that was eviscera- 
tion of the eye, and closure of the anterior opening with sutures. 
He thought this better than enucleation, and it gave a better 
stump for the artificial eye. 

Extraction of the Lens in its Capsule.— Dr. D. B. St. John 
Roosa, of New York, said that for the past three years he had 
been in the habit of removing the lens in its capsule, in a large 
proportion of cases without iridectomy. The section was made 
as usual, but large. After puncture and counter-puncture were 
made, the knife was turned on its back so that it rested on the 
iris. It was then moved up and down two or three times until 
the lens was seen to move; then the section was completed, and 
the lens could usually be removed without loss of vitreous. 
Sometimes after the operation the iris was rolled under, but in 
many cases the pupil was circular. Dr. Roosa had performed 
the operation between thirty and forty times, and was satisfied 
with his success. 

Sub-conjunctival Luxation of the Lens.— Dr. George C. 
Harlan, of Philadelphia, reported two cases. In the first case 
no operation was recommended, as vision was good. In the 
second case the lens was removed. In those exceptional cases 
in which vision remained, the operator should think twice be- 
fore resorting to removal. 

Dislocation of the Lens under Tenon's Capsule.— Dr. 0. 
F. Wadsworth, of Boston, reported a case in which the eye 
had been injured two weeks before the patient came under ob- 
servation. There was loss of sight, pain about the eye and irri- 
tation of the other eye, the cornea was hazy, and there was 
blood in the anterior chamber. The eye was enucleated, and it 
was found that the lens was beneath Tenon's capsule, and that 
it was held in this position by inflammatory tissue. 

The Treatment of Purulent Conjunctivitis.— Dr. J. A. 
Andrews, of New York, read a paper on this subject in which 
he said that the treatment was based upon the belief that the 
contagious element was of the micrococcus variety. He related 
a case in which he had secured an inoculation of the seventh 
generation of a pure cultivation of a gonococcus. This was the 
first case inoculated with the gonococcus. Ho exhibited an 
instrument which ho had devised to wash out the conjunctival 
cul-de-sac. It consisted of an eye speculum with hollow arms 
through which fluid might be passed. He had found bichloride- 
of-mercury solution (1 to 10,000) serviceable, but apt to irritate. 
A six-per-cent. solution of boric acid was also found efficient. 



104 



PROCEEDINGS 



OF SOCIETIES. 



[N. Y. Med. Joi n., 



A two-per-cent. solution of carbolic acid was useful, as it in- 
hibited the movements of the white corpuscles. Irrigation should 
be maintained for ten minutes in order to remove all secretion. 
Nitrate-of-silver solution (two to twelve per cent.) was then 
used, and an antiseptic dressing was next applied. This con- 
sisted of vaseline and boric acid or carbolic acid; but he laid 
especial stress upon the importance of maintaining irrigation of 
the conjunctiva by means of the instrument referred to. 

Abscess of both Frontal Sinuses.— Dr. Charles S. Bull, of 
New York, related a case in which the patient had been hit on 
the forehead fourteen years previously with a piece of wood. 
This produced a fracture of both nasal bones and deviation of 
the septum. In seven weeks the wound had closed. Ten years 
after the accident a swelling was noted at the upper inner angle 
of the right orbit which could be made to disappear by pressure. 
There was complete ptosis. An incision was made into the 
swelling just beneath the orbital margin and a large quantity of 
pus escaped (two or three ounces). The cavity was washed 
with a five-per-cent. solution of carbolic acid. The septum be- 
tween the two frontal sinuses was absorbed and both sinuses 
were converted into large cavities. The entire ethmoid bone 
was an immense cavity, the bony suture being absorbed. A 
number of osteophites were removed and a drainage-tube was 
introduced. The patient was discharged six weeks after the 
operation and recovered completely. The ptosis disappeared 
and the eye was restored to the normal plane. 

Dr. Knapp recommended the substitution of a silver tube 
for the rubber drainage-tube usually employed. 

Bony Tumor of the Orbit.— Dr. B. E. Fryer, of Kansas City, 
Mo., related the case of a boy six years of age who came under 
observation in April, 1885. There was swelling of the left orbit, 
which included the whole line of the superciliary ridge. It was 
quite hard. The boy had been struck with a piece of wood. It 
was decided to remove the tumor. This was done, and, on 
examination, it proved to be a cyst within which was a small 
piece of wood. This was inclosed in bone on all sides. The 
edges of the wound were brought together and healing resulted 
without complication. 

Sarcoma of the Orbit in a Child.— Dr. W. H. Carmalt, of 
New Haven, Conn., reported the case of a child of ten years of 
age from whom he removed a small growth from the upper lid. 
Six weeks later the growth had returned. An exploratory 
operation was done, and it was found that the growth extended 
into the orbit, and that it was impossible to remove it entirely. 
It was therefore decided not to complete the operation. The 
child had since died, and the tumor proved to be a rapidly 
growing sarcoma. He thought that, if in young children the 
tumor appeared to be quickly recurrent and not easily isolated, 
no operative interference should be attempted. 

Dr. Kipp, of Newark, thought that in many cases these 
tumors of the orbit were not primary, but secondary, and that 
the primary tumor might be in such a position as not to attract 
attention. 

Dr. Harlan, of Philadelphia, reported several instances of 
nflammatory exudations in the orbit simulating tumors, and 
illustrating the importance of exercising great care in diagnosis. 

Some of the Results obtained in the Compilation of 
1,000 Cases of Refraction.— Dr. E. E. Holt, of Portland, Me^ 
had been in the habit of recording all the measurements con- 
nected with the prescribing of glasses. As a result, he had 
found, in 1,000 cases thus recorded, the average distance be- 
tween the centers of the pupils of the human eye to be about 
60 mm. The average of other measurements was given, and 
the importance of the physician determining and designating 
them, and then seeing that they were carried out, was dwelt 
upon. 



Rapidly Progressive Myopia checked by Section of the 
External Rectus.— Dr. Harlan related the case of a boy of 
sixteen in whom myopia was progressing rapidly. The exter- 
nal rectus was divided seven years ago. The internal rectus 
was also excised by the use of prisms. Since then there has 
been no increase of the myopia. 

Progressive Astigmatism.— Dr. Samuel Theobald, of Bal- 
timore, related three cases of this affection. 

Afternoon Session. 

Hypermetropic Refraction passing into Myopic Re- 
fraction. — Dr. S. D. Risley, of Philadelphia, had on previous 
occasions called attention to five cases of a similar kiDd, and the 
object of his paper was simply to report six additional cases 
seen within the past year. 

The Demonstration of Refraction and Accommodation. 
— An apparatus for this purpose was exhibited by Dr. Luoien 
Howe, of Buffalo, N. Y. It consisted of two bands of thin 
metal bent in such a manner as to represent the outlines of a 
double convex lens, and passing through it were two jointed 
rods representing the raj's of light ordinarily figured as pass- 
ing through such a lens and joining at its focus. The flexible 
bands were attached to each other above and below, so that, 
by approaching or separating the sides, they could be made to 
show less or greater convexity. The rods representing the rays 
of light were jointed near the center in such a way that while 
the two halves could be placed in such a direction as to show 
the light as entering parallel to the axis of the lens, the other 
two portions could be beat to a point to show the convergence 
of rays at the focus. By alteration in the position of these 
rods, and also in the forms of the bands representing the lens, 
all the different variations of the laws of refraction and the 
changes in accommodation could be demonstrated to a class. 

Two Cases of Unilateral Temporal Hemianopsia. — Dr. 
C. S. Bull read a paper with this title. [It will be published 
in full in a future number of the journal.] 

Penetration of the Eyeball with Scissors in the Operation 
for Strabismus. — Dr. H. Derby, of Boston, reported two cases, 
the first of which was that of a young man on whom an operation 
for strabismus had been attempted. The surgeon inadvertently 
picked up a pair of sharp-pointed scissors. The point of the 
scissors suddenly penetrated the eyeball, and a portion of vitre- 
ous, equal in size to a cherry-stone, escaped. The operation 
was abandoned, and Dr. Derby was called to see the case. The 
eye was bandaged and the patient put to bed. Several attacks 
of inflammation supervened, but the patient was discharged on 
the forty-first day with V = T V 

In the second case the scissors also entered the sclerotic, but, 
after a somewhat tedious convalescence, the wound was found 
closed on the twenty-first day with vision as good as before the 
operation. 

Dr. Knapp stated that he had done three thousand squint 
operations, and in three cases he had punctured the sclerotic. 
He, however, completed the division of the muscle, and the pa- 
tients recovered as readily as from an uncomplicated operation. 

Dr. Mittendorf thought that in case the accident happened 
the division of the muscle should be completed. 

Dr. E. Williams reported a case in which he had punctured 
the eye. The patient recovered without difficulty. 

Strabismus ; its Correction when Excessive and in High 
Degrees of Amblyopia.— Dr. E. E. Holt read a paper with 
this title, in which he said that he had employed advancement 
of the weakened, attenuated muscle in connection with tenoto- 
my in certain cases of squint, and after tenotomy alone had 
failed to correct the deviation. He also exhibited an apparatus 
that he had devised for showing the associated and accommoda- 



July 25, 1S85.J 



PROCEEDINGS OF SOCIETIES. 



105 



tive movements of the eyes and the effects of tenotomy and ad- 
vancement of the muscle in correcting squint. 

Dr. Kipp had at one time employed advancement, hut he 
had given it up because it was difficult to graduate the result. 

The Treatment of Strabismus Interims.— Dr. W. W. 
Seely, of Cincinnati, read a paper with this title, and from 
which lie made the following deductions: 1. That, with out- 
present knowledge, routine operative interference is wrong. 2. 
That to thoroughly correct the deviation in young children by 
operative interference is extremely liable to subject them in 
after life to insufficiency or external squint. 3. That a later 
period of life, if anything, favors better results from operative 
interference. 

Dr. Knapp considered advancement a dangerous operation. 
He had always been able to correct the deviation by two or 
three tenotomies, and, if necessary, by stitching the eye to the 
commisure. 

Dr. Theobald indorsed Dr. Knapp's views in reference to 
advaucement. He was surprised at the conclusions of Dr. 
Seely. Squint operations in his hands had been very satisfac- 
tory: If postponed, they were likely to prove unsatisfactory on 
account of the amblyopia which was liable to develop. 

Dr. 0. F. Wadsworth had convinced himself that amblyo- 
pia from squint did not occur. The ability of the patient to use 
the vision which he had seemed to be lost by a continuance of 
the squint, but it might be recovered by practice. 

Ectropion of Both Lids ; Blepharoplasty by the Italian 
Method.— Dr. R. H. Derby, of New York, reported a case in 
which the displacement of the lids was the result of cicatricial 
tissue from a severe and extensive burn of the face. The lids 
were loosened from their attachments, and the new lids were 
formed from flaps raised from the arm. The aim was bound to 
the head with water-glass plaster, and the pedicle was not 
divided until union had taken place. 

Plastic Operations without Pedicles. — Dr. B. Joy Jef- 
fries, of Boston, read a paper with this title, in which he sug- 
gested the use of the prepuce from the circumcision of Jewish 
children for operations about the eyes. He also suggested that 
in plastic operations the desired result might be obtained with- 
out the use of a flap by employing carbolized-oil dressings to 
retard healing. 

( To be concluded.) 

AMERICAN OTOLOGICAL SOCIETY. 

Eighteenth Annual Meeting, held in New London, Conn., 
Tuesday, July 1^, 1885. 

The President, Dr. C. H. Burnett, of Philadelphia, in the Chair. 

Dr. Charles J. Kipp, of Newark, showed a copy of Retzius's 
work on the "Anatomy of the Organ of Hearing in Vertebrate 
Animals." 

The President reported the deaths of two members during 
the year — Dr. John H. Dix, of Boston, and Dr. Edward T. Ely, 
of New York. 

Inflammation of the Attic of the Tympanum.— Dr. Sam- 
uel Sexton, of New York, read a paper in which he first re- 
ferred to the importance of inflammation arising in the attic as 
compared with that arising in the atrium. The atticus tympanicus 
was described as that portion of the tympanum lying above a 
plane extending transversely from the prominence on the inner 
wall, formed by the external semicircular and facial canals, to 
the auditory plate on the outside. Beneath this plane lay the 
atrium tympanicum. Over the attic arches were the tegmen, 
which also covered the antrum, the petro-mastoid canal, a vary- 
ing number of cellules, and the Eustachian tube. The attic com- 
municated freely with the antrum by means of the petro-mastoid 



canal of Sappey. The mastoid antrum lay behind and to the 
outer side of the attic, in the spongy substance of the mastoid. 
It was usually larger than the attic, and, as a rule, extended 
downward among the cellules of the mastoid process, giving off 
frequently a small passage, communicating with the cellules 
overlying the external auditory meatus. The attic was divided 
below into two compartments, the inner being the larger, by the 
incus and malleus, the cord, ligaments, etc., which formed a 
partial antero-posterior partition. These compartments com- 
municated freely with each other above, with the atrium below, 
with the Eustachian tube in front, and with the antrum behind. 
The outer compartment was wedge-shaped, larger above, and 
shut in below by the close approximation of the large ossicles to 
the auditory plate, except anteriorly and posteriorly, where two 
small openings allowed of drainage into the atrium below. The 
inner compartment also communicated with the atrium by an 
elliptical opening surrounded on the inner side by the facial 
canal and on the outer by the large ossicles, the cord, ligaments, 
etc. All these cavities were lined throughout with mucous 
membrane. Acute inflammation of the attic might result from 
catarrh of the head, the exanthemata, or the entrance of fluids 
propelled along the Eustachian tube in bathing or from the 
use of the nasal douche. Irritating fluids seemed always to be 
better borne in the lower than in the upper part of the tym- 
panum. Inflammation of the attic might occur in connection 
with, or be independent of, inflammation of the atrium. It was 
the more serious from the fact that swelling of the mucous mem- 
brane clogged the outlets and prevented drainage. In such cases 
the membrana flaccida was red, the vascular turgescence extend- 
ing above into the external auditory canal and sometimes down- 
ward about the short process of the mallet. Should the disease 
progress further, the inflammation might extend beneath the 
margo tympanicus of the auditory plate, and be followed by 
effusion of serum and blood, which pressed away the membrana 
flaccida and the integument of the canal, producing a bulging 
sac so great sometimes as to entirely conceal the membrana 
tympani, and it might entirely fill the canal and present at the 
lumen as a purplish tumor. Periostitis of the surrounding parts 
might occur and extend along the surfaces of the canal, and 
inflammation might spread to the atrium ; hut, so long as this 
did not occur and the membrana tympani was unaffected, there 
might be little deafness, though autophonia might be present. 
In nearly all these cases inflammation in some degree extended 
into the antrum and mastoid cellules, or those overlying the 
external auditory canal, or those situated in the tegmen. If the 
escape of secretions into the atrium or Eustachian tube was 
prevented, the case was more severe and extension to the cranial 
cavity more to be feared. 

The proper treatment was to effect drainage and employ 
such constitutional remedies as tended to check the inflamma- 
tion and prevent the formation of pus, such as aconite, calx sul- 
phurata, etc. It was impossible to make an accurate differential 
diagnosis between the pains of pachymeningitis and the neuralgic 
pains of otitis media. The surgeon should therefore be cautious 
about trephining the mastoid where pain was the only symptom. 
After pachymeningitis had set in, it was manifestly useless to 
perforin this operation. 

Dr. D. B. St. John Roosa, of New York, thought that the 
remedies mentioned, mercury and calcium sulphide, were not in 
common use in the way recommended by the author. He had 
used them without any favorable effect. A warm room, a 
good nurse, taking care of the bowels, and local measures were 
the most important. The internal treatment should be expect- 
ant. He would like Dr. Sexton to describe a case indicating 
the manner in which he would use these remedies. 

Dr. Sexton stated that the particular point of his paper was 



106 



PROCEEDINGS OF SOCIETIES. 



[N. Y. Med. Jock., 



in regard to the inflammation of the attic, and not the use of 
remedies. The moment there were symptoms of puruleney he 
administered the calcium sulphide. 

Dr. J. A. Andrews, of New York, referred to a case in 
which the inflammation was most intense in the upper part of 
the tympanic cavity, and a perforation was estahlished between 
the mastoid antrum and the external auditory canal. There 
was a great deal of swelling of the external auditory canal. 
Examination under ether showed a fluctuating swelling in t lie 
superior-posterior part of the canal, which was incised, and 
considerable blood and pus escaped. 

Dr. 0. D. Pomekoy, of New York, asked if Dr. Sexton be- 
lieved that mercury relieved the pain. 

Dr. Sexton had never used it exclusively to relieve pain, and 
had not recommended it for that purpose. For the relief of 
pain he would recommend the use of aconite and pulsatilla, the 
latter especially. 

Dr. C. R. Agnew, of New York, said that when there was 
acute otitis media it was desirable to cut it short as soon as pos- 
sible. If a patient came to him with the symptoms of begin- 
ning otitis media lie would give him fifteen grains of calomel 
and order a Turkish bath if that was accessible. With children 
there was always a certain amount of indefiniteness in the 
symptoms. He asked Dr. Sexton what he would do in a case 
of acute otitis media catarrhalis in an infant six months old. 

Dr. Sexton would examine the history. If there was an 
accumulation he would let it out. In the majority of cases at 
this age the membrane had already ruptured when the case 
came under observation. If there was suppuration, he would 
give calcium sulphide. If there was simply catarrh, he would 
give mercury. 

Dr. Kipp spoke of the value of inflation of the middle ear. 
This relieved the pain. Where there was protrusion in front of 
the membrane, incision gave relief. 

Dr. Theobald, of Baltimore, had found the instillation of a 
warm solution of atropine of great service, a solution of the 
strength of four grains to the ounce. He had used pyrophos- 
phate of sodium in fifteen-grain doses in inflammation of the 
middle ear with threatened mastoid implication, aud was con- 
vinced that it was of real value. 

Dr. C. J. Blake, of Boston, referred to a reduplication of the 
mucous membrane in the upper portion of the tympanic cavity, 
which he had found in fifteen or twenty per cent, of two hun- 
dred specimens examined. This served to separate the upper 
portion of the tympanic cavity from the lower. It became an 
important element in inflammation of this part, and might tend 
to retain secretions. 

Dr. Sexton had used mercury and sulphide of calcium for 
the last ten years in many cases, and was convinced that they 
were beneficial in a certain number. 

The Treatment of Chronic Otitis Media.— Dr. W. W. 
Seelt, of Cincinnati, read a paper with this title, which closed 
with the following conclusions: 1. Only long observation (often 
lasting over months) in each case could determine whether 
treatment should be continuous (daily) or interrupted — i. e., 
perhaps daily for a week, followed by an interruption of some 
weeks or months. 2. Only experience in each case could inform 
us whether treatment was to be entirely directed to the middle 
ear, or entirely to the naso-pharynx, or combined against both. 
3. Only experience in each case could inform us whether injec- 
tions into the cavitas tympani were called for. Under this head 
it was stated that direct medication, either of the middle ear or 
the naso-pharynx, as routine treatment, was unwise till simple 
inflation had failed. 4. Mechanical dilatation of the tubes was 
rarely necessary or advisable; only in extremely dry states of 
the tube was dilatation followed by much success. 5. Hearing- 



tests were not reliable, and hence patients with great deafness, 
great loss of bone conduction, etc., should not be sent away til) 
the test by trial had been gone through with. 6. Simple in- 
flation failing, the greatest attention should be given to the 
naso-pharynx, even though it was apparently in a fair condition. 
7. Syringing, douching, and swabbing the naso-pharynx should 
be abandoned. 

The Relations between Chronic Catarrhal Otitis Media 
and Chronic Rhinitis. — The President read a paper in which 
he stated that he had found a constant causal relation between 
chronic catarrh of the middle ear and chronic rhinitis and rhino- 
pharyngitis. The latter was chiefly of the hypertrophic form. 
The atrophic form constituted about fourteen and a half per 
cent. The appearances of the membrana tympani in the first 
class were very diversified — so much so as to preclude a deter- 
mination of the state of the middle ear and hearing from them 
alone. In the atrophic class, the symptoms presented by the 
membrana tympani were more uniform and consistent, and the 
surgeon was able to determine from them more precisely con- 
cerning the aural disease. Yet, on the whole, the appearances 
of the drum, taken by themselves, could not aid greatly in the 
diagnosis of chronic aural catarrh. Tinnitus aurium was, as a 
rule, more marked in the atrophic class than in the hypertrophic, 
There was also a greater patency of the Eustachian tube in the 
atrophic forms than in the hypertrophic. It was most relieved 
by treatment of the nares and naso-pharynx. The treatment 
in the first class should be by cleansing and astringent sprays, 
with applications of preparations of iodine never stronger than 
half-and-half. Nitrate of silver was not to be used at all in 
hypertrophic rhinitis. In the atrophic form, the treatment was 
cleansing, the removal of inspissations if they occurred, and the 
application of stimulant sprays, preferably of nitrate of silver, 
not stronger than four grains to the ounce of water. Where 
the hypertrophies had become dense and large, requiring surgi- 
cal removal, the case should pass into the hands of the rhinolo- 
gist. A word of caution was given in regard to the use of the 
galvanic cautery in the nares, since, like the nasal douche, it 
might lead to inflammation in the naso-pharynx and middle ear. 

Dr. Agnew thought there was an anatomical objection to the 
use of salves, and that was the impossibility of applying them 
to the whole of the diseased surface by means of Bowman's 
probe. He was not prepared to accept the law that the nasal 
syringe should be abandoned. He thought more stress should 
have been laid on hygiene, which was the most important ele- 
ment in the treatment. 

Dr. Roosa also considered that the principal and only bene- 
fit to be obtained in the majority of these cases was from proper 
hygiene; it was not necessary to continue examinations very 
long or repeat them very often to determine whether or not 
relief might be expected. If there was diminished bone con- 
duction, it was useless to go on and treat the patient. 

Dr. H. Knapp, of New York, had employed in his own 
person a salve of iodoform with vaseline with considerable 
advantage. 

Dr. Seely had had more satisfaction from salves than from 
any other treatment. They remained longer in contact with 
the affected part than solutions, thus giving a more decided 
effect. 

Afternoon Session. 
Dr. Sexton presented a conversation tube for the aural in- 
struction of deaf-mutes. By means of this tube the patient was 
able to hear his own voice and compare it with the voice of his 
teacher. 

Professor Graham Bell called attention to the great num- 
ber of children classed as deaf-mutes who, under proper edu- 
cation, could be made simply hard-hearing members of society. 



July 25, 1885.1 



PROCEEDINGS 



OF SOCIETIES. 



107 



A Case of Fatal Ear Disease beginning as a Circum- 
scribed Inflammation of the External Auditory Canal.— Dr. 

Kipp read the history of the case of a married woman, aged 
twenty-eight years, who was first seen nine months hefore her 
death. Since a confinement, four months hefore, she had suf- 
fered occasionally with severe pain in and ahout the left ear. 
There were swelling and redness of the posterior upper wall of 
the external canal. There was no perforation and no otorrhoea. 
Under the use of leeches, instillations of morphine, and infla- 
tion of the middle ear, there was decided improvement in the 
course of a month, when she passed from under observation. 
Eight or nine months later the pain again appeared, shortly 
after a confinement. Examination of the ear showed great 
swelling of the external canal, but the tympanic membrane and 
the middle ear appeared to be normal, and there was no tender- 
ness over the mastoid. The patient recovered from this attack, 
but the pain in the head continued, and she finally died. At the 
autopsy there was found evidence of intense inflammation over 
the entire exteut of the arachnoid and pia mater. There was a 
collection of pus immediately over the posterior surface of the 
petrous portion of the temporal bone. Pus was also found on 
the pons Varolii. A small abscess was found in the anterior 
part of the left lobe of the cerebellum, near its junction with 
the pons. The mastoid cells were filled with pus. There was 
only a thin exudation in the middle ear. 

The President reported a case similar in many respects, in 
which the patient died from what was diagnosticated as cere- 
bral abscess, but no autopsy could be obtained. 

Dr. E. E. Holt, of Portland, Me., reported the present con- 
dition of a patient from whom teratoid tumors had been re- 
moved two years ago, and in whom the disease had returned in 
one year. 

The Local Use of Cocaine and Brucine in Diseases of the 
Ear. — The President read a paper in which he said that he had 
used the sulphate and the hydrochlorate of cocaine to produce 
anaesthesia in painful affections of the ear. Neither was effi- 
cient when the pain was due to inflammation of the dense tis- 
sues of the external auditory canal, nor when acute inflamma- 
tion occurred in chronically thickened periosteal and mucous 
tissues in the tympanic cavity. A four-per-cent. solution of the 
hydrochlorate induced anaesthesia in congestion of the skin of 
the fundus of the auditory canal and in the membrana flaccida 
where the pain was not too intense and continuous. The solu- 
tion was applied directly to the affected part, while the canal 
was illuminated by the head-mirror. The anaesthesia of the 
external auditory canal produced by cocaine was not profound 
enough to permit of painless incision into it. He had also used 
brucine in a five-per-cent. solution with success in producing 
local anaesthesia. 

Does Cocaine Hydrochlorate, while relieving the Pain 
in Acute Otitis Media, prolong the Congestion?— Dr. Holt 
read a paper with this title. This question had occurred to him 
several times where he had used the remedy for the relief of 
pain in the middle ear. He was satisfied that, while cocaine 
relieved the pain, and for the time held the inflammation in 
check, yet, after the effect of the remedy passed off, the inflam- 
mation went on unaffected. 

On the Desirability of adopting a Uniform Method of 
expressing the Results of testing the Acuteness of Hear- 
ing was the title of a paper read by Dr. Knapp, in which the 
following method of record was suggested : 

H = ||, normal hearing for a watch. 

H = |§, normal hearing for the whispered voice. 

H = normal hearing for conversational speech. 

II = whisper or speech heard, hut not understood (quali- 
tative perception of sound). 



H 60' = O, voice not heard at all. 

H = O, complete deafness for all sounds. 

Q 

H = — , a watch of 24" hearing distance heard on contact 
24' 

with ear. 

Pr. 

H — — , a watch of 24" hearing distance heard when 
24 

pressed on ear. 
M 

H = — , a watch of 24" hearing distance heard when ap- 
24 » 

plied to mastoid. 

T 

H = — , a watch of 24" hearing distance heard when ap- 
24 6 

plied to temple. 

H — — , a watch of 24" hearing distance heard when ap- 
24 

plied to teeth. 

H = — ', a watch of 24" hearing distance heard when ap- 
24 

plied to forehead (glabella). 
V 

H = , a watch of 24" hearing distance heard when ap- 
24 

plied to vertex. 

II = — — , a watch of 24" hearing distance heard when ap- 
24' b 

plied anywhere (unique). 

To indicate that the watch was not heard at the places 

C M 

enumerated, the following were used : H — = 0, H — = 0, 

etc. II = O would mean that bone-conduction for the 
24 

watch was lost. 

Presbykusis. — In a paper with this title, Dr. Roosa applied 
the term to the failure of hearing incident to old age and not 
dependent upon inflammatory affections. It came on after the 
age of forty or fifty years. Such persons heard badly in a noisy 
room. They beard the watch badly, but in a quiet room they 
could hear quite well. This was characteristic of the affection. 
In inflammatory troubles with the ear, the person often could 
hear pretty well in a noise, while in a quiet room he heard badly. 
These three symptoms went together : diminished bone-conduc- 
tion, difficulty of hearing in a noise, and disproportion between 
ability to hear the voice and ability to hear the watch. The 
conditions on which presbykusis depended had not been deter- 
mined, for as yet there had been no opportunities for post- 
mortem examinations. 

Dr. Sexton exhibited a glass ear-syringe and an ear forceps 
with several attachments. 

Dr. E. Dyer, of Newport, R. I., reported on a case of fistula 
of the helix, in a girl of fourteen, which he had greatly benefited 
by the application of the galvanic cautery. 

The following papers were read by title : " A Case of Chronic 
Otitis Media Suppurativa, resulting in Cerebellar Abscess, with 
the Autopsy," by Dr. O. D. Pomeroy, of New York ; " Otitis 
Media Suppurativa, Mastoid Disease, Pyaemia, Mastoid Opera- 
tion, Recovery," by Dr. G. Bacon, of New York. 

Officers for the Ensuing Year were then elected as fol- 
lows: President, Dr. J. S. Prout; Vice-president, Dr. S. Sox- 
ton; Secretary and Treasurer, Dr. -I. J. B. Vormyne ; Publica- 
tion Committee, Dr. Vermyno, Dr. Blake, and Dr. J. 0. Green; 
Committee on Membership, Dr. Carmalt, Dr. Kip]), and Dr. 
Theobald. 

Dr. F. L. Capron, of Providence, R. I., was elected to mem- 
bership. 



108 



PROCEEDINGS OF SOCIETIES. 



[N. Y. Mkd. Jock. 



NEW YORK OBSTETRICAL SOCIETY. 

Meeting of February 3, 1885. 
The President, Dr. William M. Polk, in the Chair. 

Placenta Prseviaand Twin Pregnancy.— Dr. H. T. Hanks 
had recently heen requested by Dr. Dull to see a patient with 
placenta pnevia, who, after the seventh month, had lost so much 
blood that it was decided to effect an early delivery. After giv- 
ing ether, Dr. Bull introduced his hand into the uterus, seized 
the foot of the child, and extracted it, not waiting, on account 
of the amount of blood which had been lost, for uterine con- 
tractions. The placenta did not come away at once, and it was 
found that there was a second child, which al*o was extracted 
by the feet. The placenta was double. Very little blood 
was lost after the extraction of the first child. Both children 
were living, but one, being quite weakly, died within a few 
days. 

Dr. R. A. Murray inquired whether there had been repeated 
haemorrhages, or only a single severe one. 

Dr. Hanks replied that there had been slight attacks of 
haemorrhage for a few weeks before delivery. 

Dr. Murray had made the inquiry because, in his experience, 
cases of placenta pnevia, so far as haemorrhage was concerned, 
fell into two classes; those in which there was a slight drib- 
bling of blood for some time before term, and those in which 
there was but a single attack of haemorrhage, which was severe 
and occurred at the onset of labor. In the latter class the 
haemorrhage would almost certainly prove fatal to the child. 
He referred to two instances which could be attested by certain 
members of the society. In one the woman was in perfect 
health, and had been out driving the day before an extremely 
severe haemorrhage took place, which rendered her pulseless a£ 
the wrist and in the femorals, and caused the death of the 
child. 

Sarcoma of the Abdominal Wall and Peritonaeum.— Dr. 

J. B. Hunter related the case of a woman of stout build, forty- 
five years of age, who, about a year ago, noticed what she called 
a small lump, just above the umbilicus, which was increasing in 
size. A month ago the tumor appeared to be about four inches 
in length and two and a half in breadth, irregular in outline, and 
situated just above the umbilicus. At the latter point there was 
an ulceration, which gave forth an offensive discharge. The 
diag_w*is lay between sarcoma and fibroma. An incision hav- 
ing been made across the tumor and the finger introduced, the 
growth began to shell out like a fibroid from its capsule, but at 
its lower border, while scarcely any effort was being made, the 
finger entered the peritoneal cavity, and it was found that the 
growth was attached to the omentum. It was removed with 
very little difficulty. The peritonaeum was then found to have 
on its surface little masses of epithelioma which bled easily- 
Further exploration revealed a second tumor, similar to the one 
removed, extending from the umbilicus nearly down to the 
pubes, and apparently covering the greater part of the interior 
of the abdomen with its flattened surface. It had had no con- 
nection with the first tumor. The peritoneal opening made dur- 
ing the removal of the upper growth was two inches and a half 
in length, and was closed with difficulty on account of the de- 
generated condition of the membrane. A drainage-tube was 
inserted into the wound and an iodoform dressing applied. 
Unexpectedly the patient survived, and had no bad symptoms 
whatever. The drainage-tube was still in situ, and from it some 
offensive pus had been withdrawn by aspiration. The patient 
would be able to return to her home, although the malignant 
disease would remain uncured. Dr. Hunter was disposed to 
think the growth originated in the abdominal wall. 



Ovulation in One Ovary at a Time.— Dr. H. C. Cue re- 
ferred to an idea which had been termed rather fanciful, viz., ( 
that ovulation took place in but one ovary at a time. He had 
recently observed a few cases which seemed to confirm that 
view. In three or four instances the patients suffered no pain 
at one menstrual period, while at the next there was alwayf 
severe dysmenorrhea, and in all but one of the patients the 
ovary on the side to which the pain was referred, the left, w&f 
enlarged and prolapsed. 

Dr. Hanks asked Dr. Coe if he had observed whether the 
corpora lutea in the two ovaries were apparently of the same or 
of different dates. 

Dr. Coe replied in the negative. 

Dr. Hunter said that in one case of intense dysmenorrhea, 
referred to the right ovary, which was enlarged, he removed 
the ovary and the symptoms disappeared for a year. The left 
ovary was closely adherent, and was not removed. With the 
return of the symptoms he attempted to remove the other 
ovary, but gave up the operation on account of the extent of 
the adhesions. This case seemed to support the theory men- 
tioned by Dr. Coe. 

Dr. Hanks had two patients under observation whose 
sufferings were much more severe at alternate menstrual 
periods. 

Vaginal Hysterectomy.— Dr. P. F. Munde presented a 
uterus and related the following history: About two months 
ago the woman was sent from the out-door department of Mt. 
Sinai Hospital to his clinic, and her case was found to be a 
typical one of epithelioma confined to the lips of a lacerated 
cervix. Apparently the disease did not extend a line beyond 
the lips, and, as the case seemed to be a very favorable one for 
hysterectomy, he advised the patient to have the operation 
done without delay. But she did not return for two months, 
and at that time desired to have the operation performed. The 
lips of the cervix were then much more infiltrated, but the dis- 
ease had not extended into the parametrium. The uterus was 
still perfectly movable. The greatest obstacle in the operation 
was the narrowness of the vagina; it was difficult to expose 
the cervix in the vaginal vault. The operation was performed 
on the afternoon of the fourth day before the meeting. As in 
two former cases he had experienced some difficulty in reaching 
the broad ligaments and introducing ligatures with the patient 
upon the side, in the present instance be undertook Martin's 
method, with the patient upon the back. In this position, how- 
ever, he found it almost impossible to reach Douglas's pouch, 
and, on account of the presence of the specula, it was with the 
greatest difficulty that he was enabled to lift the peritonaeum 
with the finger. In the other cases, with the- patient on the 
side, and using Sims's speculum, this step in the operation was 
attended by no difficulty whatever. Having finally brought the 
fundus of the uterus outside the vulva, he was able to pass the 
ligatures and separate the side attachments with ease. The 
elastic ligature having broken, he was obliged to use silk upon 
the left side. Each vessel was ligated separately and little 
blood was lost — perhaps as much as twelve ounces in all. 
There was a slight amount of oozing from the posterior inci- 
sion, between the peritonaeum and the vaginal wall, which 
might have been avoided had he been able to pass sutures as he 
had tried to do. The operation consumed about an hour and a 
half. It would have been shortened had the first part been per- 
formed with the patient upon the side, turning her upon the 
back to evert the uterus and ligate the ligaments. The patient 
remained pulseless at the wrist, and died thirty hours after the 
operation. 

The lessons which the case taught were, first, those concern- 
ing the technicalities of the operation, and, second, those relat- 



July 25, 1865. j 



PROCEEDINGS 



OF SOCIETIES. 



109 



ing to its justifiability. As bearing on the indications of the 
Operation, lie referred to a paper which he read at the last 
meeting of the American Gym-ecological Society. The oftener 
we performed an operation the more dexterous would we be- 
come, and the more successful would be the results. In the 
paper referred to he had maintained that hysterectomy ought 
to be performed in suitable cases of cancer of the uterus, and 
he was of the same opinion still, although he might hesitate 
longer before undertaking it. 

Dr. Hanks said he had never removed the uterus, but he 
bad often used the galvanic or Paquelin's cautery in cancerous 
cases, and he would ask Dr. Munde whether he would not 
have been justified in first giving the patient the benefit of a 
trial of that method of treatment. Was it not just one of those 
cases in which this form of treatment would have been indi- 
cated ? If the cautery did not cure the disease, it certainly 
arrested its progress, and afterward, if necessary, removal of 
the entire uterus might be resorted to. He had witnessed the 
hysterectomy in several cases, and he believed that in the ma- 
jority of instances in this city the result had been unsatisfactory. 
If, then, we could prolong life six months or a year, or even a 
longer time, by the old method of partial removal of the uterus, 
should it not be preferred to entire removal of the organ? He 
doubted if we were justified in removing the uterus in cases in 
which the cervix alone was involved; the risk was too great. 

Dr. MrsiiE asked Dr. HaDks in what manner he would 
operate. 

Dr. Hanks replied that he would destroy the diseased tissue 
by means of the galvanic tip. 

Dr. Munde said he might have done too much, but he 
thought Dr. Hanks would have done too little. If the patient 
had declined to have hysterectomy performed, he would then 
have drawn the cervix down to the vulva, made a circular in- 
cision through the. vaginal vault all round, and amputated the 
cervix with the galvanic cautery as high as possible without 
touching the peritonaeum or bladder. He thought this method 
better than Schroder's, in which the cervix was amputated with 
the knife and the raw surfaces were united with sutures. 

Dr. Hanks had no particular choice as to the manner in 
which the cervical tissue was removed by the cautery, but the 
point was that partial removal of the uterus was preferable to 
hysterectomy. He knew of at least six women who had lived 
a year, eighteen months, or two years after the use of the cau- 
tery. 

Dr. Munde said, in reply to a question, that in thirty-nine 
per cent, of the cases of removal of the uterus the women had 
remained well two years after the operation. Seventy -two per 
cent, recovered from the operation. Those were better figures 
than could be shown for any palliative treatment. 

Dr. Hunter had a patient who had lived nine or ten years 
after the removal of undoubted epithelioma of the cervix. He 
thought hysterectomy would ultimately be limited to sarcoma 
of the fundus. 

Dr. Coe had seen Braun undertake to remove the uterus 
with the patient upon the back, and fail because of the want of 
room within the vagina. 

A Large Hsematoma. — Dr. Munde said that two weeks ago 
a woman came to Mt. Sinai Hospital with the history that six 
weeks before she had had a miscarriage, and afterward had had 
fever and a great deal of abdominal pain, and she gave an in- 
distinct history of diffuse cellulitis. By gaslight her complex- 
ion was waxy yellow or cachectic. A tumor was found occupy- 
ing the whole of the posterior portion of the pelvic cavity, the 
cervix being pushed against the pubic symphysis. It apparently 
contained fluid, and was supposed to be a pelvic abscess of very 
large size. The next morning the patient was seen by daylight, 



and her complexion was less yellow, and this fact, with that of 
the withdrawal of only blood by aspiration, led to the diagnosis 
of haematoma. The patient's condition was not favorable, but 
it was believed that absorption of so large a quantity of blood 
would not take place, and he therefore proceeded at once to 
make an incision, two inches in length, at the point of greatest 
tension in the posterior vaginal wall. Eighteen ounces of co- 
agulated blood escaped. A tumor was then recognized within 
the cavity, of the size, form, and consistence of the human 
heart. The patient's condition did not seem to justify him in 
manipulating the tumor to discover its exact nature, but it was 
thought it might be a sarcoma. The cavity was washed out 
with a solution of corrosive sublimate, 1 to 5,000, a drainage- 
tube was introduced, and also iodoform gauze. Within a day 
or two frequent irrigations with the disinfectant were begun, 
but the temperature rose to 103° to 104° F., falling after each 
irrigation. As it was evident that the rise of temperature was 
of septic origin, the cavity of the hasmatoma was explored, and 
the tumor referred to, composed of coagulated blood, was found 
to be breaking down. It was scraped out, and weighed eight 
ounces; the cavity from which it came measured five inches in 
diameter. The irrigations had been kept up, the temperature 
had fallen, and the patient was doing well. He did not think 
absorption of the fluid would have taken place had it been 
allowed to remain ; the largest lmematocele which he had known 
to he absorbed was not larger than his two fists. In this case 
it was extra-peritoneal. 

Perforation of the Cervix Uteri by a Laminaria Tent.— 
Dr. C. C. Lee related a case which suggested the advisability of 
caution in using laminaria tents for dilating the cervix uteri. 
The patient, a middle-aged single woman, entered his service at 
the Woman's Hospital with what was believed to be a submu- 
cous fibroid attached to the anterior wall of the uterus a short 
distance above the internal os. The vagina was narrow and the 
cervix long, making it difficult to outline the growth with the 
finger, and, as frequent haemorrhages pointed to the necessity 
of adopting some efficient mode of treatment, it was decided to 
dilate the cervical canal. Laminaria tents were introduced, 
carefully watched, and changed sufficiently often. They were 
held in positiou by carefully adjusted vaginal tampons, which 
were never very tightly packed. The uterus was slightly ante- 
verted. On the removal of the tents on the last occasion — they 
had not been put in by himself, but by a careful and experienced 
bouse surgeon — he was astonished to find a large perforation on 
the anterior surface of the cervix at the internal os. It was 
evident that these tents, of which two were then in the canal, 
had, by their expansion and by the pressure of the tampon, per- 
forated the anterior side of the cervix at the vaginal junction. 
This was the first time he had known the accident to occur, but, 
on inquiry among his friends, he had learned of two other simi- 
lar cases, the tents used being of laminaria. In his case, instead 
of making the usual incision, he divided the cervix posteriorly 
up to the internal os, and anteriorly up to the perforation, and 
was then able to reach the greater portion of the tumor. Car- 
bolized cotton was applied to the cervix, and the patient, not- 
withstanding her reduced condition, recovered. The result of 
the granulating surfaces was such as to call for trachelorrhaphy, 
after which the cervix was left in a pretty fair condition. 

Dr. Munde bad met with cases in which an ulcer in the wall 
of a long cervix had been formed by stem pessaries and tents 
which the physician had failed to introduce through the inter- 
nal os. In some cases a little force was required to push the 
instrument through the internal os, and he had no doubt that 
inexperienced or careless persons might make a mistake and 
cause an injury of the cervical wall. A laminaria tent would 
be more likely to cause ulceration than one of tupelo. 



110 



MISCELLANY. 



IN. Y. Mku. Jour., 



Dr. Lee remarked that it was possible the tent used in this 
case was a tupelo instead of laminaria, but he thought it was the 
latter. The accident could not have arisen from the cause spo- 
ken of by Dr. Munde, because the internal os was well dilated 
when the last tent was removed. He could readily understand, 
however, that, if a tent was not made to pass the internal os, it 
might press against the solid tissue of the wall and cause ulcera- 
tion. 

Exfoliation of the Mucous Membrane of the Rectum.— 

Dr. Munde had recently performed Emmet's operation upon the 
prolapsed vagina in two cases, the immediate result in both be- 
ing perfectly satisfactory. In one there was a temperature of 
from 101° to 102° F., which was not regarded as having any 
special significance. On the tenth day, when he was about to 
remove some of the stitches, the house surgeon called his atten- 
tion to a slough protruding from the rectum. He then exam- 
ined the patient, and removed fully six inches of the mucous 
membrane of the rectum, which was gangrenous and very offen- 
sive. He supposed there would finally be stricture of the rec- 
tum. Was it possible that narrowing of the posterior vaginal 
wall could have interfered with the rectal circulation and pro- 
duced the result? In reply to a question, he said rectal etheri- 
zation had not been employed. 

Dr. Hanks referred to a case in which there was discharge 
of a part of the mucous membrane of the rectum every few 
weeks, and asked what the treatment should be. This patient 
had retroversion, and formerly casts of the lining membrane of 
the uterus were discharged. 

Dr. Munde further remarked that he believed this condition 
was called exfoliative colitis. About ten years ago Dr. Peaslee" 
presented long casts of the mucous membrane of the bowel. Dr. 
Munde had seen two instances, in one of which there was retro- 
version of the uterus, and in the other chronic oophoritis. He 
did not have an opportunity to institute treatment for the rectal 
trouble. 

Dr. C. Mackenzie inquired whether any of the patients had 
suffered from diarrhoea. He had seen a case in which there was 
morning diarrhoea, with marked retroversion of the uterus, and 
more recently a fissure of the anus had been discovered. 

Henry J. Garrigues, M. D., 

B. F. Dawson, M. D., 

Frank P. Foster, M. D., ex officio, 

Committee on Publication. 



§1 r s z 1 1 1 a rt p . 



The Failure of the American Medical Association to organize the 
Ninth International Medical Congress. — The following appeared in 
the editorial columns of the " Maryland Medical Journal " for July 
18th : "Those members of the medical profession who have an earnest 
and abiding interest in the growth of scientific medicine and in the de- 
velopment of the highest aims of the profession in this country can not 
but feel the need of a national organization thoroughly capable of meet- 
ing the highest purposes of a scientific body. The American Medical 
Association has undertaken for some years past to represent the real 
wants of the American profession. It is, however, a delegated body, 
and in the very nature of its structure contains such inherent weakness 
that it has not been able to grapple with the serious questions which 
have been propounded to it. The membership of the association is as 
fluctuating as its actions, and it has so controlled the interests of the 
profession as to forfeit the right of respect to which the organization 
is entitled from the leading minds in the profession. The association 



has never been able to do the highest order of scientific work, and from 
year to year has so constructed its offices and committees in the inter- 
ests of its floating membership that it was not capable of drawing into 
its ranks the full force and strength of the profession in this country. 
The association has shown itself totally incapable of dealing with serious 
and important scientific interests, as has been most conspicuously demon- 
strated by its recent action at New Orleans in referenc*e to the Ninth 
International Medical Congress, which it proposed to hold under its 
auspices. It was shown at New Orleans that a few determined and 
bold men were capable of capturing its membership and of upturning 
all of the work delegated to an important committee at its previous 
meeting in Washington. The result of this action of the association 
has cast a shame and a blot upon the good name of the entire profes- 
sion in this country, and it has forfeited all the reputation the associa- 
tion may have had as a fair, liberal, and high-toned scientific body. 
Under the leadership of a few malcontents the association has degen- 
erated to the level of a ridiculous and pharisaical institution, utterly 
unworthy of confidence and respect. So far as the fortunes of the In- 
ternational Medical Congress are concerned, it is now evident that the 
association is wholly incapable of conducting the Congress under its 
auspices. The withdrawal of the leading members of the profession 
from all connection with the present organization tells its own story, 
and very plainly says the Congress must be re-organized on some other 
basis than the one proposed by the American Medical Association, if it 
is to be a success. In other words, the association has so seriously 
blundered in this affair that it must resign its authority as a leading 
spirit in the re-organization of the Congress. Indeed, it seems to us 
that the only course now left open to the association is to abstain from 
further participation in the arrangements for the Congress, and that it 
leave this matter in the han':s of the medical profession at large, which 
can be depended upon to re-organize the Congress on a successful basis. 
We have no doubt that the profession at large can move intelligently 
in this matter. If representative men from all sections of the country 
can be brought together to confer upon the present outlook of the Con- 
gress, arrangements can be made which will bring order out of chaos, 
and set the affairs of the Congress on a sure and influential footing." 

The Missouri State Board of Health announces the appointment of 
committees to make special investigations as follow-: 

Prevailing diseases among live stock in Missouri ; also condition and 
care of stock-yards, cars, etc., at points of concentration or distribution 
— Committee: Mr. Gentry and Mr. Prather. The influential factors in 
the causation of endemic or local epidemic diseases — Committee: Dr- 
Griffith and Dr. Homan. The sources, quality, means of distribution, 
etc., of public water supplies in Missouri — Committee : Dr. Merrell and 
Dr. Cox. The sanitary care of railway and river transportation lines, 
including depots, landings, stations, wharf-boats, round-houses, and pas- 
senger and sleeping coaches — Committee: Dr. Homan and Mr. Gentry, 
Domestic and general sanitation in towns, villages, and country-homes — 
Committee : Dr. Goben and Dr. Griffith. The condition of asvlums, 
poorhouses, jails, workhouses, and other charitable or penal institutions 
with reference to the health of the inmates — Committee: Mr. Prather 
and Dr. Merrell. The hygienic care of the school population and of 
public-school buildings and premises — Committee : Dr. Cox and Dr- 
Goben. 

The Western Society for Psychical Research has been organized in 
Chicago, the purpose of which is to be commended, since it proposes 
to investigate certain matters most of which are usually left to enthu- 
siasts and charlatans. From an excellent address by the president, Dr. 
A. Reeves Jackson, we learn that the work of the society has been 
divided among five sections : 1. Thought-transference. 2. Hypnotism, 
clairvoyance, and somnambulism. 3. Apparitions and haunted houses. 
4. Physical phenomena. 5. Psychopathy (including what is popularly 
known as mind-cure, faith-cure, metaphysical treatment, magnetic heal- 
ing, etc.). 

The Nomenclature of Auscultation and Percussion Signs. — The 

"Glasgow Medical Journal" publishes the following tabular list of 
terms proposed by the British members and the American member of 
the committee appointed at the meeting of the International Congress 



July 25, 1885.1 



MISCELLANY. 



Ill 



in 1881 to report on a uniform nomenclature of physical signs which 
occur in connection with the respiratory system : 

PALPATION. 

AMERICAN LIST. 

Dr. Austin Flint. 
Vocal fremitus. 



BRITISH LIST. 

Dr. Powell and Dr. Mahomed. 

1. Vocal fremitus. 

2. Rhonchal fremitus. 
S. Fremitus. 



Rhonchal fremitus. 
Friction fremitus. 



1. Tympanitic .resonance. 

2. Amphoric resonance. 

3. Diminished resonance. 

ness. 

4. Absence of resonance. 

ness. 

5. Increased resonance. 



PERCUSSION. 

Tympanitic resonance. 
Amphoric resonance. 
Diminished resonance. 



Dull- 



Flat- 



Dullness. 



Absence of resonance. Flatness. 

Increased or vesiculotympanitic 

resonance. 
Not included. 



6. Bell sound. [" This term," says 
the reporter, " is applied, by 
some English writers, to a 
sound produced by percussion, 
a coin being used as a plex- 
imeter, and the ear applied to 
the chest. It is supposed to 
be characteristic of pneumo- 
thorax."] 

AUSCULTATION. 
First Group. Varieties of Breath Sounds. 

1. Exaggerated. Syn. Puerile. Exaggerated, etc. 

Compensatory. Supplement- 
ary. 

2. Diminished. Syn. Feeble. Diminished, etc. 

Weakened vesicular murmur. 

3. Suppressed. Syn. Absence of Suppressed, etc. 

breath sound. 

4. Prolonged expiration. General Prolonged expiration. High or low 

or local. in pitch. 

5. Interrupted respiration. Syn. Interrupted inspiration, etc. 

Jerking, wavy, cog-wheeled. 

6. Tubular. Syn. Bronchial. High- , Tubular. Bronchial. 

pitched blowing. 

7. Vesiculo-tuhular. Syn. Bron- Broncho-vesicular. Syn. Vesiculo- 

cho-vesicular. Harsh, coarse, tubular, 
sub-tubular. 

8. Amphoric. Amphoric. 

9. Cavernous. Cavernous. 



Second Group, 

1. Rhonchi. Dry musical sounds, 

(a) Sonorous, (b) Sibilant. 

2. Stridor. 

3. Rales. Syn. Bubbling rales, 

etc. (a) Medium, (b) Large. 
High or low in pitch. 

4. Gurgling. 

5. Clicking. 

6. Crepitation. Syn. Crepitant 

rale. 

7. Metallic tinkling. Metallic tinkling 

8. Splash. Splash. 

9. Friction, (a) Dry, (b) Moist. Friction. 

Third Group. Varieties of Voice Sounds. 



Adventitious Sounds. 

Rhonchi, or dry bronchial rales. 

(a) Sonorous, (ft) Sibilant. 
Stridor. 

Moist or bubbling rales, (a) Me- 
dium, (b) Large, (c) Small. 
High or low in pitch. 
Gurgling. 
Clicking. 

Crepitant rale, or crepitation. 



1. Increase of vocal resonance. 

2. Diminution or absence of vocal 

resonance. 

3. Bronchophony. 

4. Pectoriloquy. 

5. jfCgophony. 



Increase of vocal resonance. 
Diminution or absence of vocal 

resonance. 
Bronchophony. 
Pectoriloquy. 
vEgophony. 



The Sanitary Convention at Ypsilanti, Michigan, held June 30th 
and July 1st, was attended by about twenty physicians and health 
officers from other places, besides the physicians of Ypsilanti, the offi- 
cers of the State board of health, and a number of prominent citizens. 
Among the physicians who took part in the proceedings were Dr. Avery, 
of Greenville; Dr. Vaughan, of Ann Arbor; Dr. Whelan, of Hillsdale, 
Dr. Kellogg, of Battle Creek; Dr. Palmer, of Ann Arbor; Dr. Kinne, 
Dr. Wight, and Dr. Lyster, of Detroit ; and Dr. French, of Ypsilanti. 
Much interest was manifested in the proceedings by the citizens of 
Ypsilanti. These periodical semi-popular conferences seem to be a 
happy device of the State board of health. 

The Editor of the " British Medical Journal," Mr. Ernest Hart, is 
reported to be a candidate for a seat in Parliament, and to have prom- 
ised that, in case he is elected, he will vote for the unconditional repeal 
of the Contagious Diseases Acts (referring to venereal diseases). The 
" Medical Times and Gazette " remarks that " there is a great excuse 
for medical men, worried by the everlasting opposition to their benevo- 
lent intentions, throwing up the sponge and saying, as Mr. Hart prac- 
tically does, ' Well, have your own way, but don't blame me if it turns 
out badly.' " 

Boston and the International Medical CongTess. — The " Medical 
News " learns that the following-named gentlemen have asked to have 
their names added to the list of signers of the resolutions adopted in 
Boston declining to hold office in the proposed Congress as now organ- 
ized : 0. W. Holmes, William H. Baker, David W. Cheever, James C. 
White, and William F. Whitney, of Boston; G. P. Conn, of Concord, 
N. H. ; F. H. Gerrish and S. C. Gordon, of Portland, Me. ; E. P. Hurd, 
of Newburyport, Mass. ; and Nathan Allen, of Lowell, Mass. 

The New York Polyclinic. — We congratulate the faculty of the 
Polyclinic upon the continued prosperity of the institution. It appears 
by the annual announcement for the session of 1885 to 1886 that the 
session which opened September 22, 1884, was attended by two hundred 
and twenty-nine practitioners. From the beginning the Polyclinic has 
been under excellent management, and there can be no doubt of its 
enduring success. 

The International Medical Congress. — Dr. W. A. Hardaway, of St. 
Louis, asks us to state that he has sent in his resignation as president 
of the Section in Dermatology and Syphilis of the Ninth International 
Medical Congress. We learn that Dr. Thomas T. Sabine, of New York, 
and Dr. Thad. A. Reamy, of Cincinnati, have declined to serve in the 
positions to which they were appointed by the new committee. The 
" Medical News " announces that Dr. George J. Engelmann, of St. Louis, 
has resigned from the committee. 

The Capias served on Dr. Shoemaker in Chicago has, as we learn 
from the " Philadelphia Press," been quashed. It was in an action 
brought against him by a Mr. Merritt, of Troy, N. Y. 



THERAPEUTICAL NOTES. 

An Untoward Effect of Arsenic on the Skin in Children. — Guaita 
("Arch, di Patol. Infantil." ; " Dtsch. Med.-Ztg."), who seems to use 
Fowler's solution freely in the treatment of children's diseases, continu- 
ing its administration for four or five months, and increasing the daily 
amount given from two drops to eighteen or twenty, reports that, in 
fourteen out of eighty cases, he has observed a peculiar blackish dis- 
coloration of the skin as a consequence. It appears either toward the 
close of the aisenical course or, more rarely, about a month after its 
completion. It shows itself at first on the neck, and then on the 
breast, the abdomen, and the hands, while it either spares the face, the 
lower limbs, and the back altogether or is less pronounced on those 
parts. It is never accompanied by other disturbances, and it disap- 
pears in at least a month, with marked desquamation. It appeals from 
citations in the same journal that a dusky discoloration of the skin was 
long ago noticed as one of the effects of the prolonged use of arsenic, 
even in the form of baths of arsenical mineral waters. 

Old and New Methods of treating Congenital Syphilis. — Pro- 
fessor Monti, of Vienna, contributes to the "Archiv fiir Kindcrheil- 



112 



MISCELLANY. 



[N. Y. Mki.. JotoK. 



kunde " an article which the " Deutsche Medizinal-Zeitung " thus sum- 
marizes : In the inunction treatment, use has been made of mercurial 
ointment, oleate of mercury, Beyersdorf and Unna's mercurial-plaster 
preparation, and mercurial soap. All these substances are very prompt 
in their action, and, used in proper quantities, never give rise to saliva- 
tion or signs of irritation of the mucous membrane of the mouth, but 
they are not suitable for sucklings, for, besides their irritating the skin 
and producing erythema, eczema, and boils, the too rapid and extensive 
absorption of the mercury may lead to a quickly developed ansemia, 
often resulting in cerebral or pulmonary oedema and putting a stop to 
the child's increase in weight, in spite of judicious feeding. Since the 
inunction treatment, moreover, neither shortens the duration of the 
disease nor diminishes the frequency of relapses and sequelae, the use 
of calomel associated with iron is much more to be recommended, for 
instance after this formula : 

Calomel 1 .} grain ; 

Lactate of iron 3 grains ; 

White sugar 45 " 

Divide into ten powders. 

From one to four are to be given daily, according to the weight of 
the child. 

Calomel may be given continuously, without deranging the digestive 
apparatus, until all the syphilitic manifestations have disappeared. If, 
however, in spite of the minuteness of the dose, anaemia shows itself, 
the treatment must be interrupted at once, and lactate of iron given, 
or, in case of cerebral anaemia, the ethereal tincture of chloride of iron. 
After every course of treatment with calomel, Monti uses the follow- 
ing : 

Saccharated iodide of iron.. . . 15 grains; 

White sugar 30 " 

Divide into ten powders, from one to three of which are to be given 
daily, according to the child's age, their use being kept up until there 
is no longer any enlargement of the spleen and the skin has regained 
its healthy tint. Monti has observed that, under this method of treat- 
ment, relapses are less common and less severe, sequelae, especially 
rickets, are lighter, and the children gain in weight. 

If intestinal disturbances contra-indicate the internal administration 
of calomel, or if threatening symptoms seem to call for more energetic 
treatment, the drug may be used subcutaneously, after this formula : 

Calomel 8 to 15 grains ; 

Gum mixture, ) „„, „ . . 

' V each 75 minims. 

Glycerin, ) 

From half a syringeful to a syringeful to be injected every second 
or third day, preferably over the chest-wall. Abscesses will often form, 
in spite of the utmost care in the use of the injections. 

Van Swieten's solution (a one-to-one-thousand solution of corrosive 
sublimate) was used by that author in doses of ten drops, in milk, three 
times a day, the dose being gradually increased until a hundred drops 
were taken daily ; orjie prescribed : 

Corrosive sublimate -f grain ; 

Distilled water 10 drachms; 

Syrup U 

From two to four teaspoonfuls to be taken daily, after eating. 
In the form of baths, corrosive sublimate is very slow in its action, 
and is employed only when the internal administration of mercury is 
inadmissible. The following formula is given : 

Corrosive sublimate 15 grains; 

Chloride of ammonium 2 J drachms; 

Distilled water 6 ounces. 

To be added to two baths. 

Corrosive sublimate is most adapted to injections. [The formula 
which follows this statement seems to contain a dangerous error; we 
therefore do not reproduce it.] The injections are generally well borne, 
although not so welt as by adults, and they do their work more speedily 
than other methods of treatment. Abscesses and indurations of the 
subcutaneous cellular tissue occur. The duration of the disease and the 
occurrence of relapses and sequelae are not affected by the injections ; 
within the first two years of life the treatment should be repeated from 



four to eight times (being continued from five to twenty days each 
time), in order to effect a radical cure. 

Albuminate of mercury is equally efficient in the form of injections, 
but the solution does not keep well ; it is apt to become turbid, and 
then it causes abscesses, etc. Peptonate of mercury keeps better, but 
it has no advantages, and the same is true of formamide of meri ury. 
injections of which are very painful. 

Protiodide of mercury is very serviceable, especially in affections of 
the bones : 

Protiodide of mercury l£ grain; 

Lactate of iron 3 • grains ; 

White sugar 45 » 

Divide into ten powders; from one to three to be taken daily. 

Severe colic and intestinal catarrh are commonly produced by this 
drug, even when opium is used with it. 

Henoch often employs black oxide of mercury, in the form of pow- 
ders, carrying the dose up to a seventh of a grain, twice a day ; but 
Monti has found that it frequently causes vomiting. 

Tannate of mercury, from one seventh to half a grain, from two to 
four times a day, is very well borne and is quite as rapid and favorable 
in its action as calomel. 

As regards the iodine treatment, Monti gives from three to six pap- 
spoonfuls [? daily] of a one-per-cent. solution of iodide of potassium, 
and adds from three to eight drachms of the iodide to the bath. The 
tardy action of the drug and its interference with the nutrition when 
its use is long continued have led the author to prefer the saccharated 
iodide of iron, which is especially well borne by children, never causes 
iodism, and corrects anaemia ; but it is suitable only in cases where 
energetic treatment is not indicated. For children between three and 
twelve months old, it is sufficient to give from a third to half a grain, 
in milk, three or four times a day; children from a year to two years 
of age may take from four grains and a half to six grains daily. 

Silk-worm Gut as a Material for Ligatures. — Guermonprez and 
Bigo lately submitted a communication to the Paris Soeiete de therapeu- 
tique (" Gaz. hebdom. de med. et de chir.") on the use of crin de Flo- 
rence in surgery. They conclude that, if its ends are cut off and it is 
macerated for at least a month in a watery antiseptic solution (it must 
not be boiled), it is the best thread for sutures. It is tenacious, pliable, 
and better borne by the tissues than either hemp, linen, or silk. For 
ligatures applied to small vessels it is not so good as catgut, but for 
large vessels and the pedicles of tumors it is to be preferred. 

The Paradoxical Action of Quinine. — Merkel ("Dtsch. Arch. f. klin. 
Med." ; " Ctrlbl. f. klin. Med.") relates the case of a woman who had 
fever which was taken to be malarial. She was given three grains of 
hydrochlorate of quinine, and in an hour she showed faintness, weak- 
ness, and stupor. She then had a chill, and her rectal temperature rose 
to 104 - 6° F. The temperature fell gradually without the occurrence of 
sweating. The same effects were produced whenever a small dose of 
quinine was given. 

A Dressing for Phagedenic Chancre. — The " Union medicale " at- 
tributes the following formula to Terrillon : 

Pyrogallic acid 1 part ; 

Powdered starch 4 parts. 

Mix carefully. In cases of ragged phagedenic chancres, with multi- 
ple prolongations, the powder is to be blown into the deep parts with a 
bellows. The application should be repeated twice a day. The prepa- 
ration should be freshly made and preserved against moisture in a well- 
corked bottle. 

A Diuretic Mixture. — The same journal credits Billroth with the 
following formula : 

Acetate of potassium, / , - 

r ' > each 5 parts ; 

Nitrate of potassium, ) 

Distilled water 200 " 

Syrup of raspberry 20 " 

A teaspoonful to be given night and morning in cases of acute artic- 
ular rheumatism. The affected joints are to be painted with tincture of 
iodine, covered with cotton, and kept absolutely motionless. If peri- 
carditis occurs, a blister is to be applied over the precordial region. 



THE NEW YORK MEDICAL JOURNAL, August 1, 1885. 



LECTURES ON 
ELECTRICITY IN MEDICINE, 

DELIVERED AT THE MEDICAL DEPARTMENT OF THE UNI- 
VERSITY OF VERMONT, BURLINGTON, 

By AMBROSE L. RANNEY, M. D., New Yoek. 

{Continued from page 87.) 

Galvanization of the Cervical Sympathetic. — This 
method has afforded relief, according to published cases, in 
vaso-motor and trophic disturbances of the nerve-centers, 
the eye, viscera, muscles, joints, and skin. Thus, for ex- 
ample, cases of cure of epilepsy, atrophy of the optic nerve, 
Basedow's disease, progressive muscular atrophy, lead-palsy, 
scleroderma, chronic rheumatic arthritis, bulbar paralysis, 
neuralgias of various types, and many other conditions have 
been reported by means of this method. Respecting this 
step, Erb wisely remarks as follows: "There can probably 
be no doubt of the correctness of a part of these observa- 
tions, but this does not by any means imply that the cervi- 
cal sympathetic is responsible for such results." 

When we review the structures which compose the neck 
and recall the numerous connections which exist between 
the sympathetic cords, the pneumogastric nerve, the brain 
and cervical segments of the cord, the medulla oblongata, 
the brachial and cervical plexuses of nerves, etc., it be- 
comes clear why De Watteville applies the term " sub-aural 
galvanization" and Erb the term "galvanization of the 
neck" to this special procedure. 

The steps required to influence these parts by Meyer's 
method consist in the application of a small electrode (ca- 
thode) under the angle of the jaw and adjacent to the hyoid 
bone, and then crowding it backward and upward against 
the vertebral column, the positive electrode (of larger size) 
being placed over the seventh cervical spine. The current 
may be stabile, labile, or interrupted ; or the polarity may 
be changed from time to time during the sitting of from 
one to three minutes. Six to ten galvanic cells of the 
Grenet variety are sufficient. The application may be uni- 
lateral or bilateral, according to the demands of the case. 

Corning has devised an instrument which insures carotid 
compression with galvanization of the neck for the treat- 
ment of cerebral hyperemia and some other morbid condi- 
tions. 

Benedict places the positive pole in the jugular fossa, 
and the negative pole upon the superior cervical ganglion. 

General Faradization. — This method of administer- 
ing electricity was first employed by Beard and Rockwell. 
By this procedure the entire body is subjected to secondary 
faradaic currents of varying intensity. It is applicable 
chiefly to those forms of nervous disturbance which are 
associated with general debility, poverty of the blood, spe- 
cial diatheses and cachexias, hysterical affections, skin dis- 
eases, persistent chronic inflammations, and other results of 
low vitality or functional derangements of the organs. 

To apply this method, the patient must be undressed or 



very loosely clothed. The feet are immersed in a bowl of 
tepid water with a little salt added, in which the cathode 
is also placed after being connected by means of a rheo- 
phore to the binding-post of the secondary coil of a faradaic 
machine. The anode is held in one hand of the physician, 
and his other hand (well moistened in salt water) is applied 
to all parts of the surface of the patient's body. If the 
subject can bear it, a large electrode covered with absorbent 
cotton and flannel, or with a soft sponge, is employed in place 
of the hand. The application should begin at the head and 
terminate at the feet — the strength of the current being 
modified from time to time as the feelings of the patient 
may demand. The extremities and back should have vig- 
orous stimulation, the nerves of the neck should be influ- 
enced by a much weaker current, and the coeliac plexus 
should be influenced by a stabile application of a few min- 
utes over the epigastrium. The entire duration of the 
application occupies from ten to twenty-five minutes. It 
may be applied as often as three times a week if necessary. 

Personally, I can attest the efficacy of this treatment as 
a general tonic. I have witnessed immediate effects from 
it in a large number of my cases, and I employ it constantly 
in a modified form. 

In case the hand of the attendant is to be employed as 
an electrode, I would advise you to use the instrument 
which I now show you as a great improvement over the 
way described by the inventors of this method. It is called 
the electric bracelet. It is placed upon the right wrist of 
the attendant over a pad of wet absorbent cotton, and the 
rheophore is screwed into the binding-post upon it. The 
right hand is then wet in salt water and used as previously 
described. By this instrument the hand of the attendant 
is alone subjected to the current, and the fingers can detect 
muscular contraction in the patient even when too feeble to 
be seen easily. As an adjunct to massage, I employ this 
useful instrument with decided benefit. 

General Galvanization. — The steps required by this 
method are similar to those previously described, except 
that the constant-current battery is employed in place of a 
faradaic machine. 

Central Galvanization. — The cathode is placed over 
the epigastrium. This electrode should be of large size. 
The anode is stroked over the forehead, with a current of 
about two milliamperes, for two minutes; then made stabile 
over the cranium for about two minutes; then moved up 
and down the neck on each side for the same duration ; 
finally it should be moved along the length of the spine for 
about five minutes. This method was a favorite one with 
the late Dr. Beard, who reported cures of gastralgia, hys- 
teria, hypochondriasis, nervous dyspepsia, and many of the 
symptoms of cerebral and spinal neurasthenia by its con- 
tinued use. In two cases of gastralgia in which I per- 
sonally employed it for some time I obtained an absolute 
recovery. 

The Electrical Bath. — This method of administration 
of electricity to a patient may be accomplished by usino- a 
metal tub, or one which is composed of a non-conductor. If 
a metal tub is employed, the patient must be protected 



114 PORTER: PHTHISIS AND PNEUMONIA, 



THEIR RELATION TO SYPHILIS. [N. Y. Med. Jocr., 



from actual contact with it. This is usually accomplished 
by means of wooden slats or some other medium of support 
for the patient when immersed. If the bath-tub is of 
metal, one rheophore of the battery employed is attached 
to the tub, while the other is attached to an electrode held 
by the patient or placed in contact with his body. If the 
tub is of a non-conducting material, both electrodes may be 
placed in the water. The electrodes employed should be 
very large (often running the entire length of the tub), in 
order to allow of as great a diffusion of the electricity as 
possible. The fluid in the tub may be simple water, or, 
preferable, a solution of salt, soda, or an acid. 

Personally, I am not a strong advocate of this method 
of treatment. It violates one of the fundamental principles 
of electrical treatment of localized affections in that it does 
not confine the polar action to the part or parts diseased. 
In the second place, I have not found its tonic action to 
equal that of general faradization or general galvanization. 

Strong claims have been made in its favor as a remedy 
for tremor (especially of the alcoholic and mercurial varie- 
ties) and for chronic articular rheumatism, but I am not 
yet convinced that they are to be regarded as well-estab- 
lished. 

If you desire to try this method of treatment in any 
case, it is well to know that the temperature of the bath, as 
well as the strength of the current employed, should be 
modified by the condition of your patient. The duration 
of the bath should never exceed thirty minutes, and ten 
minutes will generally suffice. The current should be strong 
enough to be perceived by the patient in all cases. 

The Relief of Painful Points. — One of the most 
generally useful effects of electricity is the relief which it 
affords in many cases to pain. Of all the methods of treat- 
ment of neuralgia now employed, I consider electricity, in 
some of its various forms of application, by far the most 
efficacious. Personally, I have almost discarded internal 
medication for the relief of this class of sufferers. You 
have personally witnessed in one or two cases brought be- 
fore you the immediate relief which follows the application 
of electricity to painful points, and you have seen neuralgia 
cured at one sitting by the same agent. Do not understand 
me, however, as maintaining that this can be accomplished 
in all cases. Repeated applications are demanded, as a rule, 
and, in some instances, months of treatment are required to 
insure a cure of this distressing malady. 

In the majority of subjects afflicted with neuralgia, pain- 
ful points may be detected along the course of the affected 
nerve or its branches. These are situated, as a rule, where 
the nerve gives off a branch or bifurcates, and also where it 
passes through a foramen. Sometimes it is necessary to 
make pressure along the course of the nerve to detect the 
existence and seat of these points. 

Now, it should be remembered by each of you that the 
successful treatment of neuralgia depends largely in some 
cases upon the direct treatment of these painful points. They 
seem in some way to have a relationship with both the pro- 
duction and cure of neuralgia, as well as spasm of the mus- 
cles, ataxic symptoms, and other forms of nervous diseases. 
These points may be the seat of a localized periostitis, a 



circumscribed inflammatory exudation, a neuritis, an en- 
larged gland, and many other conditions which create nerv- 
ous phenomena. In a few instances the symptoms even 
of ataxia have been relieved, by the electrical treatment of 
painful points in the region of the spinous and transverse 
processes of the vertebrae, by men of note, among whom 
may be mentioned Brenner, Remak, Meyer, Legros, and 
others. 

The steps which you should employ in the treatment of 
painful points are as follows : 1. Use the galvanic current, 
employing from three to eight Grenet cells. 2. Apply the 
anode to the painful spot, and keep it stationary at that 
point. 3. Place the cathode at some indifferent point, pre- 
ferably the sternum. 4. Do not use a current which will be 
excessively painful to the patient, nor exceed five minutes 
in the application. I frequently do not allow the duration 
of the current to exceed two minutes at a sitting. It is ad- 
visable, in persistent cases, to make the applications daily. 

Of late some experiments have been made, with appa- 
rent benefit, by having patients of this class wear over the 
painful points a piece of metal, connected with another piece 
of metal (which is also in contact with the skin) by an insu- 
lated wire. The best metals are zinc and copper. They 
should be brightly polished before the application, and 
should have a piece of dampened linen between them and 
the skin. They may be worn continuously for weeks, or 
changed each day on retiring and rising. 

Some authors recommend the employment of very feeble 
galvanic currents for an hour or two at each sitting, the 
anode being placed over the painful point. Le Fort goes 
so far as to suggest the propriety of applying such currents 
continuously for weeks, by r means of ordinary rheophores 
and electrodes, when fatty changes, contractures, or reflex 
paralyses are to be combated. 

[To be continued.) 



Anginal Communications. 



OBSERVATIONS ON 

PHTHISIS AND PNEUMONIA 

IN THEIR RELATION TO SYPHILIS. 

A STUDY OF ONE HUNDRED CASES IN WHICH THESE AF- 
FECTIONS WERE ASSOCIATED. 

By WILLIAM H. PORTER, M. D., 

PROFESSOR OP CLINICAL MEDICINE AND PATHOLOGY IN THE NEW TORK POST- 
GRADUATE MEDICAL SCHOOL AND HOSPITAL ; CURATOR OF THE PRESBY- 
TERIAN HOSPITAL, ETC. 

Most of the clinical data used in the preparation of this 
paper have been taken from the records of one hundred un- 
selected cases recorded at the author's medical clinic at the 
New York Post-Graduate Medical School and Hospital ; the 
pathological data from the post-mortem records of the 
Presbyterian Hospital. 

Syphilitic pneumonia in children has long been recog- 
nized as a distinct and common lesion, but in adults it is 



August 1, 1885.] PORTER: PHTHISIS AND PNEUMONIA, THEIR RELATION TO SYPHILIS. 



115 



either entirely ignored or given but a passing notice by 
the writers on clinical medicine.* 

Latent syphilis, both of the acquired and congenital 
variety, as an ajtiological factor in disease, has occupied the 
attention of the author for a number of years past, and he 
has collected much pathological material bearing not alone 
upon its influence upon the pulmonary tissue, but upon every 
organ and tissue of the body. Pulmonary syphilis is best 
defined as a condition of the lungs in which there is a pro- 
gressive thickening of the walls of the vesicles ; this change 
is often associated with inflammatory deposits, gummy for- 
mations, which, degenerated into cheesy masses, become 
encapsulated or liquefy, and give rise to cavities. The first 
is best classified as syphilitic pneumonia, the second as 
syphilitic phthisis. 

The primary origin can only be settled by accepting the 
terms syphilitic pneumonia and phthisis. 

The first necropsy in connection with a typical clinical 
history was made in 1878, and in this instance there was no 
question of the existence of acquired syphilis, and the ex- 
emption from inherited phthisis was equally positive. The 
clinical history and the results of the autopsy evidenced a 
syphilitic instead of a tubercular origin for the pulmonary 
lesion, and since this time a number of similar instances 
have been noted. 

The lungs removed from a diabetic subject f are inter- 
esting, as illustrating several important points : 

1. Pulmonary consolidation and softening, with the for- 
mation of cavities, may occur in diabetic patients independ- 
ently of any tubercular phthisical process, which strongly 
suggests a similar development under other circumstances. 

2. Consolidation, softening, and the formation of cavi- 
ties may occur without the formation of tubercles, as shown 
by the fact that no tubercle tissue, in the instance quoted, 
could be made out by the microscope, as well as by the fact 
of the absence of the Bacillus tuberculosis, which corresponds 
to Koch's theory. 

3. Taken together with a number of other necropsies, 
this one establishes, from a pathological standpoint, the ex- 
istence of a syphilitic lesion with the formation of cavities 
at the apex of the lung. 

4. It substantiates the clinical observation that syphilitic 
lesions of the lungs frequently commence and are most 
marked at the apex, and diminish from apex to base. 

5. Both lungs are involved, one usually more than the 
other. The base and anterior portions of the lungs are 
rarely involved at first. J 

* " Dictionary of Medicine," Quain, American Edition, New York, 
1883, p. 900. 

f "New York Medical Journal," January 31, 1885, p. 139; Ibid., 
April 11, 1885. 

X This form of pulmonary lesion has been quite extensively de- 
scribed by : 

Greenfield, W. S. — On Visceral Syphilis. London "Pathological 
Transactions," pp. 249, 208. London, 1877. 

Goodhard, J. F. — Phthisis of Fibroid Forms ; History of Syphilis. 
Op. citat., p. 313. 

Green, T. Henry— Syphilitic Disease of the Lung. Op. citat, p. 
331. 

Pye-Smith. — Tertiary Syphilis affecting Lung, p. 334. 



Every day cases present themselves at the clinic which 
might be diagnosticated as an ordinary disease and passed 
by, but a careful investigation invariably reveals a hidden 
syphilitic taint, which has evidently excited and has served 
to keep the disease in motion. This assertion may appear 
dogmatic, but careful investigation leads to but one result. 
If the rules for diagnosis to be laid down are found suffi- 
ciently strong to warrant an inflexible opinion, the main 
question is settled. From the histories of the first thou- 
sand cases treated at my clinic, one hundred, or ten per 
cent., were taken as the basis of this paper. Of the remain- 
ing nine hundred, many had pulmonary lesions and diseases 
of the various organs, which, in my opinion, were of syphi- 
litic origin, and which, as a rule, responded to a certain line 
of treatment. This ten per cent, of all the cases is a large 
proportion; but, if the pulmonary cases alone be taken, 
fifty per cent, or more would be traceable to the same cause. 
These facts are sufficient to attract attention, and to indicate 
how frequently syphilis may figure as a cause of disease. 

Of the one hundred patients, fifty-two were males and 
forty -eight females ; but, while these figures are true of this 
particular one hundred, they do not give the relative fre- 
quency among patients at large, for, when the whole num- 
ber treated was taken into consideration, it was found to 
be more frequent in females. 

The youngest recorded was sixteen years, the oldest 
sixty-six. The cases taken as a basis for this paper were 
arranged in ten decades, beginning at ten years, and it was 
found that six and twenty-two hundredths per cent, occurred 
in the first, eleven and thirty-three hundredths in the second, 
twelve and ten hundredths in the third, eleven and twenty- 
five hundredths in the fourth, seven and seventy-seven hun- 
dredths in the fifth, and three and sixty-eight hundredths in 
the sixth, which shows that its greatest frequency is between 
the ages of twenty and fifty, with a slight liability of the 
maximum occurring between thirty and forty. 

The question of the disease being an acquired or an in- 
herited vice is one of unquestionable importance. A careful 
study of this point, for a number of years, has led the writer 
to believe that pulmonary syphilis in adults is a very com- 
mon disease, and that it is due to either an acquired or in- 
herited taint, the latter being nearly, if not quite, as frequent 
as the former. The ground for the belief that the disease 
is frequently inherited is shown by the number of cases in 
which it appears in young persons under ten or twenty 
years of age, whose chastity can not be doubted, and in 
whom no primary symptoms have ever appeared. In op- 
position to this view may be urged a primary contagion, 
passing unnoticed, or a direct transmission by kissing some 

Mohamed, F. A. — Two Cases of Syphilitic Disease of the Lung (early 
fibroid). Op. citat., p. 339. 

Godhart, J. F. — Syphilitic Disease of the Lung. London, 1874. 

Frouenier. — " Gaz. hebd. de med. et de ehir.," 48, 49, 61. Paris, 
1875. 

Thompson, E. Reginald. — Pulmonary Syphilis. "British Medical 
Journal," Aug. 28, 1880. 

This disease has been recognized and described from Morgagni's 
time to the present. A much more extended bibliography could be ap- 
pended, but this is sufficient to show that the lesion has been recog- 
nized by eminent pathologists. 



116 



PORTER: PHTHISIS AND PNEUMONIA, THEIR RELATION TO SYPHILIS. [N. Y. Med. Jouh., 



older infected person ; these are outweighed, however, by 
the absence of primary and secondary symptoms. 

Dr. John Ferguson, of Toronto, reported a number of 
cases * where the disease occurred in young children, and 
where, all other treatment having failed, the symptoms 
yielded to an anti-syphilitic regime, and where the father, 
at a later period, inquired if Lis children's condition could 
have been influenced by his having had syphilis. 

This is proof positive of the transmission of syphilis 
during its latent period from a father to his offspring with- 
out the mother showing any signs of the disease. The 
latent period of syphilis, which lasts from ten to twenty 
years, during which there may or may not be exacerbations, 
succeeds to the active state, and usually occupies that period 
of life in which the larger number of children are generated, 
thus probably accounting for the number of cases where 
positive symptoms are present without any evidence of pri- 
mary contagion. A positive proof of the occurrence of 
this disease in the form of a pneumonia or phthisis may be 
found in the fact that these complications yield quickly and 
favorably to anti-syphilitic treatment. The larger percent- 
age among females, especially among the unmarried and 
virtuous, seems to favor inheritance. These views are those 
of a clinician and pathologist, and vary considerably from 
those advanced by syphilologists. The clinical history of a 
case of this character is explained by the pathological lesion, 
and vice versa. Whether it be of the acquired or inherited 
variety may be in doubt, but inheritance from the father's 
side is in keeping with the biblical prophecy of descent 
even to the third and fourth generations. The recognition 
of syphilis in causing and maintaining disease, especially 
when the pulmonary organs are the point of attack, would 
indicate that a large number were syphilitic and not tuber- 
cular in origin. 

In many instances patients have come to the clinic with 
the statement that some competent observer had diagnosti- 
cated an incipient phthisis, accompanying it with an unfavor- 
able prognosis. A careful interrogation usually revealed a 
specific taint, however, and, when the syphilitic pneumonia 
or phthisis had received anti-syphilitic treatment, they re- 
solved, so that to-day these patients would pass the most 
critical physical examination. Is there any direct relation 
between syphilis and tuberculosis ? Decidedly not, although 
clinically and pathologically closely allied, therapeutically 
they differ decidedly. 

The changes found in the lungs are somewhat similar to 
those of tubercular phthisis, and caused Niemeyer to re- 
mark : f "It may be difficult to decide whether the lesion be 
of a syphilitic origin or not." The lungs may be free, but, 
as a rule, they are more or less bound to the chest-walls and 
diaphragm by newly formed connective tissue, so that the 
pleural space may be completely obliterated. The pleura 
itself may vary from one eighth to one half of an inch 
(three and one hundred and twenty-five thousandths milli- 
metres to three and a half millimetres) in thickness. The 
greatest thickening is at the apices. After bisecting the 

* Phila. "Med. News," January 17, 1885, p. 66. 
\ Niemeyer's " Text-book of Practical Medicine," New York, 1881, 
vol. ii, p. 771. 



lung the following changes are found : the main lobes, and 
often the lobules, are separated by distinct bands of newly 
formed fibrillated connective tissue, which is not the case 
in a normal lung. The bronchi, particularly the smaller 
ones, undergo the same change, while the bronchial glands 
are indurated and pigmented ; the latter, however, is only 
a coincident lesion. There are numerous cheesy-looking 
masses which are recognized by a trained eye as gummy 
formations. Their cut surfaces have a sticky feel and a 
laminated capsule, which, when they have attained considera- 
ble size, is quite distinct. The smaller granules have a simi- 
lar appearance, and often look as though they could be 
readily shelled out. These neoplasms may vary, botli in 
size and shape, sometimes occurring as large as a hen's egg, 
and sometimes so small that they look like the miliary tu- 
bercle. They may occur in masses forming cheesy-looking 
patches, or they may occur in single round and isolated 
bodies. These masses are separated by degenerated pneu- 
monia or by an interstitial thickening of the pulmonary 
substance. The early stage is characterized by a diffuse 
interstitial thickening of the pulmonary tissue, often asso- 
ciated with a degenerative pneumonia peculiar to this dis- 
ease. In the latter stages cavities are not infrequent, and 
these are also found in the apex or high in the superior 
lobe. 

The advanced cases are the ones that are usually found 
on the necropsy table, while the earlier types are not infre- 
quently associated with intercurrent disease or surgical con- 
ditions ; but here the histories are very incomplete, often 
being passed without attracting any attention. A striking 
illustration of this was found in the diabetic case already 
published, where, in looking for a tubercular process, a 
typical pulmonary syphilitic lesion was found. These patho- 
logical proofs of the apex — rather than the base, and ante- 
rior portion of the lung — being the point of invasion are 
contrary to the ideas of some previous writers, but it has 
been invariably so in all the cases examined by the writer, 
both in the post-mortem room and at the clinic. These 
facts also explain the physical signs which are so marked 
during life, and substantiate their truthfulness. Macrosco- 
pically, this lesion is differentiated from the tubercular by 
the peculiar cheesy and granular gummy formations which 
have a tendency to encapsulation, and look as though they 
could be readily shelled out and easily separated from the 
surrounding pulmonary tissue. 

The microscopic appearances are varied and numerous, 
and the first thing that attracts the attention is the exten- 
sive new formation of connective tissue. In many places 
broad bands are found closely resembling tendon tissue, 
and intervening between these tense layers there is a univer- 
sal thickening of the pulmonary tissue, which also involves 
the vascular walls. The yellow elastic fibers are larger, and 
consequently appear more abundant. In many of the cases 
there is little or no pigmentation found which can be trace- 
able to inorganic substances or to blood. The absence of 
the first, of course, is indicative of the fact that the inter- 
stitial thickening is not due to the irritation of carbon, iron, 
stone, or any of the other inorganic substances, as in the 
case of some varieties of fibroid induration. The absence 



August 1, 1885.1 PORTER: PHTHISIS AND PNEUMONIA, THEIR RELATION TO SYPHILIS. 



117 



of blood pigment, on the other hand, is positive proof that 
it is not due to chronic congestion or impeded blood flow. 
This also dispenses with the idea that the dyspnoea must be 
due to the stagnation of the blood. 




a. 

Fig. 1. 



The thickness of the vascular walls varies from one 
twelve hundredth of an inch (20-833 m. m. m.) to one two 
hundredth (24-999 m. m. m.), but in the majority of the 
cases they are one eight hundredth to one six hundredth 
of an inch (31-250 m. m. m. to 41-666 m. m. m). (See Fig. 
1, a.) In a number of instances the capillaries were seen in 
the center of these thickened bands (Fig. 1, x), the walls 
of which were thickened independently of the vascular 
tissue. When the vessels were distended with blood, as 
in Fig. 1, x, the thickness of the tissue intervening be- 
tween the lumen of the blood capillary and the wall of the 
air-sac could be measured, and was found to be from one 
twelve hundredth to one four hundredth of an inch (20-833 
to 62-500 ra. m. m.). 

This would naturally impede the free and easy inter- 
change of gases between the two cavities, and would explain 
why the dyspnoea in this disease was so profound. 

In addition, the connective tissue presents four charac- 
teristics microscopically : 

1. Dense bands of white fibrous tissue with few cor- 
puscular elements. 

2. A less dense tissue studded with numerous small, 
round inflammatory corpuscles, having an average diameter 
of one one hundredth of an inch (4*166 m. m. m.). At 
other points, this same connective tissue was thickly set 
with oat-shaped corpuscles one thirteen hundredth of an 
inch (19-230 m. m. m.) long and one eight thousandth of 
an inch (3-002 m. m. m.) broad. 

3. The same inflammatory basement substance, inter- 
spersed with round nucleated corpuscles, one forty-five hun- 



dredth of an inch (4-166 m. m. m.) in diameter, which, taken 
alone, looked not unlike a round-cell sarcoma. 




Fig. 3. 



4. The thickened bands had a granular and degener- 
ated appearance. 

In many of the ultimate bronchi there was marked fibroid 
thickening, and many of the vesicular spaces were filled 
with an inflammatory exudation which presented a variety 
of appearances : 

1. The air-spaces were filled with red-blood disks, leu- 
cocytes, desquamated epithelium, and fibrillated fibrin iden- 
tical with that found in the second stage of a lobar pneu- 
monia. (Fig. 1, b.) 

2. Others were filled with decolorized round cells, as in 
gray hepatization of lobar pneumonia. (Fig. 1, c.) 

3. Others were filled with large, round, distinctly nucle- 
ated epithelium cells, with a diameter varying from one fif- 
teen hundredth to one two thousandth. (Fig. l,d.) 

4. Others contained a granular degenerating material 
which would not stain. (Fig. 1, e.) 

The marked feature of this change was that all four con- 
ditions were irregularly intermingled as though in each air- 
sac it ran its course independently of all the rest, going regu- 
larly through the red and gray hepatization ; at this point 
degeneration, rather than resolution, set in. The thickened 
walls prevent absorption, and the degenerating inflammatory 
products probably account for the copious expectoration. 

This process is best classed as a degenerative pneumonia 
and one peculiar to syphilis. This peculiar pneumonia, 
associated as it is with diminished elasticity, and with dila- 
tation of the bronchial tubes and loss of resilience on the 
part of the lungs, explains the absence of both dry and 
moist rales. The dilated and moist condition of the bron- 
chi accounts for the absence of sibilant or sonorous sounds 
which are so common in the ordinary forms of interstitial 
pneumonia. This same condition of affairs accounts for 
the absence of the crepitant and subcrepitant rales, because 
the walls of the bronchi are not able to approximate each 
other and cause the sounds. 



118 



PORTER: PHTHISIS AND PNEUMONIA, 



THEIR RELATION TO SYPHILIS. [N. Y. Med. Jode., 



My opinion has always been that these rales were due to 
the opening and shutting of the ultimate bronchi, and a 
careful study of the physical signs and of a number of sec- 
tions has still further convinced me that this is the way in 
which these sounds are produced. But I do not care to say 
that this is the only way in which they are produced, as 
they are often heard in certain stages of pleuritic inflamma- 
tions, and there is no point of diagnosis between the two 
that is practical. The pleuritic rale, however, is very much 
less frequent. 

It is well known that there is no tidal motion to the air 
beyond the third division of the bronchi. Beyond this 
point the air is changed by diffusion and by an anatomico- 
physiological law. 

The trachea and bronchi are lined throughout with co- 
lumnar ciliated epithelium, and the current of motion pro- 
duced by these cilia is from within outward at the periph- 
ery of the lumen, while the central column of air is constantly 
moving downward. 

It is by this action of the epithelium that the major 
part, if not the whole, of all inflammatory exudations into 
the air-sacs and smaller bronchi are brought up to the larger 
bronchi, where they can be influenced by the tidal air. 
The mass of sputum is pushed up until it reaches the under 
surface of the true vocal cords, where it irritates the periph- 
eral sensory filaments of the superior laryngeal nerve, through 
which it is reflected back to the cough center, when a deep 
inspiration and a spasmodic or complete closure of the 
chink of the glottis follow. This is in turn followed by a 
forced inspiration with the glottis closed, during which 
the glottis opens, allowing a sudden escape of a large quan- 
tity of air under a very high pressure. The result of this 
is that the mass of sputum is driven through the rima glot- 
tidis into the larynx, mouth, or outside world, according to 
the force of the inspiratory act. This constitutes what is 
known as coughing, and is simply a dislodgment of the con- 
tents of the superior portion of the trachea. Irritation of 
the peripheral fibers of the pneumogastric in the pleura or 
bronchi will produce a dry or hacking cough. A thorough 
appreciation of these anatomico-physiological laws and their 
application to pathological conditions is absolutely essential 
for the selection of proper therapeutic agents. 

Professor Thomas E. Satterthwaite first called my atten- 
tion to the true value of the ciliated epithelium. The large 
gummata have a peculiar laminated, fibro-vascular, connective- 
tissue periphery which tends to encapsulate and isolate their 
granular centers. The surrounding pulmonary substance is 
the seat of a peculiar fibro- and degenerative pneumonia. 
The capsules are highly vascular, the small vessels having 
thickened walls from hyaline transformation (Fig. 3, d) ; the 
center often liquefies, the contents being discharged through 
a bronchus, leaving a smooth cavity in the pulmonary tissue. 
These cavities may contract and form a cicatricial " pock- 
mark," or they may remain stationary for months. On the 
other hand, they may ulcerate and extend, so that at the ne- 
cropsy we would find small smooth-walled cavities, together 
with larger ones with ragged walls, or sometimes with walls 
similar to those occurring with a tubercular phthisis. 

Throughout lungs affected in this way small miliary 



bodies closely resembling miliary tubercle are abundant, 
but they are not opaque or transparent. These bodies I 
have called miliary gummata. These gummata sometimes 





Fig. 3. — Gummy Tubercle showing - Cheesy Center, Fibrillated Con- 
nective-Tissue Capsule, and Hyaline Thickening of Blood-Ves- 
sels. a, surrounding puimonary tissue ; b, cheesy center ; c, sharply 
defined filirillated connective-tissue capsule ; d, thickened capillaries show- 
ing hyaline metamorphosis. 

coalesce, but at first they are round and isolated. A close 
study of these, in comparison with miliary tubercle, shows 
that there is a vast difference between the two. The pe- 
riphery of the gumma somewhat resembles the adenoid tis- 
sue of miliary tubercle, but a high power distinctly shows 
that its periphery is composed of concentrically arranged 
fibrillated connective tissue in which numerous blood-vessels 
ramify. (Fig. 3, b, c.) The walls of these vessels, owing to a 
hyaline transformation, are invariably thickened. (Fig. 3, d.) 
As a rule, no giant-cells are found in the gumma. 

In miliar} 7 tubercle the adenoid tissue is more delicate 
and less perfectly fibrillated ; it is full of small-round cells 
and often contains giant-cells ; the capsules are less vascu- 
lar and the blood-vessels do not present the hyaline trans- 
formation. 

Taking the definition of Ziegler as the standard for mili- 
ary tubercle — i. e., " a non-vascular nodule (Knbtchen) which 
does not grow beyond a certain size, and which, having at- 
tained a certain stage of development, undergoes cheesy 
degeneration " — gummy tubercles tend to become encapsu- 
lated, miliary to soften and diffuse. Such a striking anal- 
ogy between these two forms of tubercles naturally suggests 
the following queries : 

1. Is not tuberculosis superinduced by syphilis? 

2. In the late stages of a syphilitic lung, may we not 
also have miliary tuberculosis? 

3. Have not gumma tubercles been frequently mistaken 
for miliary tubercles ? 

The first two must be answered in the negative on ac- 
count of the absence of temperature and of the Koch Bacil- 
lus tuberculosis. There is, however, no good reason why a 
tuberculosis should not be developed on a syphilitic lesion, 
but the writer has not found a single instance where the 
post mortem has revealed this. 

Before answering the next question definitely, more data 
are required to prevent confounding the two. 



August 1, 1885.] PORTER: PHTHISIS AND PNEUMONIA, THEIR RELATION TO SYPHILIS. 



119 



The rational signs in many respects resemble those of a 
tubercular phthisis. The patients complain of having had 
a heavy cold with incomplete recovery, followed by a dry, 
hacking cough, or one with an abundant muco-purulent ex- 
pectoration. The sputum is either white and frothy or 
thick, purulent, and of a greenish or yellow tinge, as in a 
true pulmonary tuberculosis. Early haemorrhages are fre- 
quent and often copious, while the dyspnoea is an early and 
pronounced symptom. Pleuritic pains are common, and 
there is often great weakness while the general physique 
remains fairly good — in fact, the emaciation is not at all in 
proportion to the weakness, and is nothing like that of the 
tubercular variety. The skin is warm and moist, but there 
is little or no elevation of the bodily temperature. Night- 
sweats are frequent and distressing, and the patient com- 
plains of cephalalgia and of indefinite and wandering pains 
in the bones and tissues, which increase at night. Dyspepsia 
and slight jaundice are not infrequent. The urine has a 
characteristic pale, limpid appearance, which, together with 
the sallow complexion, often leads to the suspicion of a ne- 
phritic lesion. The urinary examination is usually negative 
unless there happens to be a coincident renal lesion. 

Married females abort without any apparent exciting 
cause further than the syphilitic taint. Their children, if 
born, are often plump, but soon die of marasmus. The first 
child is often healthy, but the subsequent children are deli- 
cate. Frequently patients complain of sore throat and of 
an early loss of hair. 

The physical signs are peculiar and diagnostic ; the 
respiratory act is labored and all the accessory muscles of 
respiration are brought into play, but there is little or no ex- 
pansion of the chest. Early in the disease palpation reveals 
increased fremitus, but in the advanced cases it is dimin- 
ished, owing to the small volume of air entering the lung. 

Percussion gives varying degrees of dullness, which is 
most marked at the apex but diminishes toward the base. 
The percussion-note is dull and of " wooden quality," and 
localized areas of dullness are found. Owing to the fact 
that small cavities have thin walls and contain considerable 
air, the dullness is not so great as would be expected, but, 
compared with a sound chest, it is decided. 

Auscultation yields most positive and peculiar evidence 
when the rational history is taken into consideration. The 
inspiratory and expiratory murmurs are prolonged and harsh, 
especially the former, with a decided intermission between 
the two. Broncho-vesicular breathing is frequent at the apex. 
When the amphoric whisper is absent the presence of a cav- 
ity is eliminated. As a rule, crepitant and sut crepitant rales 
are absent, thus eliminating chronic bronchitis. It is differ- 
entiated from asthma by the absence of the sibilant and so- 
norous sounds. The vocal resonance is exaggerated over 
the consolidated portions. Another very strong and patho- 
gnomonic sign is a peculiar pain and oedema of the sternum 
and of the tibial crests. Pressure over these regions pro- 
duces a very peculiar pain, which is quite intense and accom- 
panied by a recoil not easily forgotten when once recog- 
nized. Patients often try to avoid giving evidence of this, 
but as surely fail as though trying to resist the muscular 
reaction to the electric current. A noticeable feature is 



that when the sternum is excessively sensitive the tibial 
crests are less so, and vice versa. There is no other disease 
in which this localized tenderness in oedema of the perios- 
teum is met with. It is never found accompanying a true 
miliary tuberculosis, but it is exceedingly common in con- 
nection with syphilis, and, from this absence in cases of 
tuberculosis where the diagnosis was confirmed by the ne- 
cropsy and its almost universal presence in cases of syphilis, 
it may be regarded as pathognomonic of a specific taint. 
In addition to this, it is always found to yield when the 
patient is under an anti-syphilitic regime. 

The diagnosis is based upon five principal signs and 
symptoms : 

1. The abundant expectoration without any signs of 
softening of the pulmonary tissue. 

2. The weak and debilitated condition without marked 
emaciation and the good rational history of phthisis. 

3. Pronounced dyspnoea without any evidence of a car- 
diac or pulmonary obstruction to the circulation. 

4. The peculiar pain and the reaction to pressure upon 
the sternum and tibial crests. 

5. The ready response to treatment is another element 
in the diagnosis. 

The prognosis depends upon the early recognition and 
treatment. Syphilitic phthisis may run a very rapid course, 
but, as a rule, it is quite chronic. Dissipation hastens its 
progress, especially when alcoholic stimulants are used to 
excess. 

In treating this affection, the liver should first be freely 
acted upon by cathartic doses of calomel or podophyllin, 
which in some cases should be frequently repeated. Expe- 
rience has shown that the mixed treatment yielded better 
results than when mercury or iodide of potassium alone was 
used. The combination most successful is one sixteenth of 
a grain of the biniodide of mercury, from five to ten grains 
of the iodide of ammonium, and ten to twenty grains of the 
iodide of potassium in a drachm of the compound tincture 
of gentian, three times a day after meals. 

Great reliance is placed on the ammonium salt, not per- 
haps on account, of its intrinsic action in syphilis, but from 
the action which it has in rendering the two others more 
soluble, capable of easier absorption and assimilation, and 
in increasing their solvent action upon these newly formed 
gummatous elements — in fact, its action may be compared 
to that of trituration on calomel. 

This is, of course, only theoretical, although it was 
taught by the late Dr. Van Buren, and may not be in 
keeping with the experience of other observers, but there 
can be no question of its efficacy in the cases in which it 
has been tried. Patients have repeatedly come under ob- 
servation in whom one hundred grains of the saturated 
solution of the iodide of potassium produced no effect, but 
who showed rapid improvement after a free catharsis and a 
maximum dose of thirty grains of the combined salts. It 
may be argued that recovery under the iodide is no sure 
proof of the existence of syphilis, as these drugs only pre- 
vent a waste of tissue and thus might retard an ordinary 
phthisis. It is, however, pretty generally acknowledged bv 
writers on therapeutics that the chief potency of the potas- 



120 



ST UK 0 IS: 



SYPHILIS. 



[N. Y. Med. Jocr., 



sium salts and iodine is due to their power of increasing 
oxidation. Upon this property our theory of their action 
has been based. Turkish and Russian baths are also of 
great service. It is quite essential to prescribe expectorants 
which will render the inflammatory exudation as watery 
and free from mucus as possible, at the same time stimu- 
lating the ciliated epithelium - cells, and thus freeing the 
air-passages of inflammatory products which tend to de- 
compose, act as irritants, and interfere with the aerating 
space. 

The best of food, air, and a total abstinence from all 
forms of dissipation must be insisted upon. The inherited 
cases are the more intractable, and will not yield to the 
iodide of potassium alone. 

The conclusions may be summed up as follows : 

1. ^Etiology. — Pulmonary lesions attributable to syphi- 
lis are very common, more so in females than in males, 
with the maximum number of cases occurring between 
thirty and forty years of age ; it is as frequently, if not 
more frequently, inherited than acquired. 

2. Pathology. — Is most frequent at the apex ; usually 
involves both lungs; is a peculiar pneumonic proce — in 
the early stages, while later cavities are formed, and it be- 
comes phthisical in the sense of progressive consolidation, 
followed by softening and the formation of cavities. There 
is a strong resemblance, but a positive difference, between 
syphilitic and tubercular phthisis, and a positive anatomi- 
cal difference between a syphilitic and a miliary tubercle. 

3. Symjitoms. — These are peculiar and diagnostic. 

4. Diagnosis. — This rests mainly upon the rational his- 
tory and physical signs, the extreme dyspnoea, the periosteal 
tenderness, and the absence of an increased bodily tempera- 
ture. 

5. Prognosis. — This depends upon an early recognition 
of the trouble. 

6. Treatment. — It must be anti-syphilitic to be of any 
avail. Many cases are unaffected by iodide of potassium 
alone, unless under enormous doses, but a rapid improve- 
ment follows upon the use of the biniodide of mercury, 
iodide of ammonium, and the iodide of potassium. 

In conclusion, thanks must be extended to Dr. George 
R. Elliot for his pains in examining the specimens for the 
bacilli, to Dr. George G. Van Schaick for the drawings, 
and to Dr. E. B. Brunn, one of the laboratory students, for 
preparing the specimens and examining for the bacilli. 

Note. — In addition to the foregoing, I would like to state that, from 
October 1, 1884, to May 15, 1885, I made forty-two necropsies. In 
eleven of the cases, or 26 - 19 per cent., there was, in my opinion, a 
syphilitic condition of the lung— either gummata or cavities. Each was 
put to the test for the bacilli of tuberculosis, and in every instance they 
were found to be absent. The last three of the eleven were also put to 
the double test for the bacilli of tuberculosis and those of syphilis, and 
in all of them the latter were found in abundance, but none of the for- 
mer. One case of the forty-two, or 2'35 per cent., had been diagnosti- 
cated as tuberculosis. The sputum was found to contain the bacilli of 
tuberculosis, and the diagnosis was confirmed by the necropsy. 

102 East Thirty-first Street. 

"Bartholow's Materia Medica and Therapeutics" is, we are in- 
formed, to be translated into French by Dr. Henri Huchard and Dr. 
Lucien Deuian, of Paris. 



SYPHILIS.* 

By F. R. STURG1S, M. D., 

PROFESSOR OF THE DISEASES OF THE OENITO-URIN ARY ORGANS, AND OF VENE- 
REAL DISEASES, IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND 
HOSPITAL ; SURGEON TO CHARITY HOSPITAL. 

The treatment of this affection should be considered 
both constitutionally and locally. In the old routine of con- 
stitutional treatment with mercury for one period, succeeded 
by another of treatment with the iodide of potassium, the 
development of the symptoms was so interfered with that 
the surgeon was left in the dark w ith regard to the stage and 
tendencies of the disease. This method fully justified Vol- 
taire's satire: "The practice of medicine was like the pur- 
suit of an imaginary enemy by a blind man armed with a 
club." Present methods, however, were not open to such a 
criticism. 

Syphilis is a complex disease, which runs a definite 
course, but which has been subjected to an arbitrary and 
misleading classification by its division into the primary, 
secondary, and tertiary stages. It would have been better 
at the first if it had been divided into the early and the late 
periods, making the division, not according to the chrono- 
logical order, but according to pathological phenomena; 
then the early manifestations would be those where there 
was no ulceration, while the appearance of an ulcerating 
process would be indicative of the later period. 

The train of symptoms in this disease is usually pro- 
gressive : first, the chancre and the non-ulcerative lesions of 
the skin, followed by the destructive processes, with, once 
in a while, cases where the whole course of the disease is 
malignant. 

In these later cases the chancre becomes phagedenic, and 
the ulceration, instead of being macular, is pustular and ulcer- 
ating, as in the so-called tertiary stage, with which it should 
be classed. There is no specific treatment for this affection. 
Although a believer in the use of mercury, I consider its 
efficacy dependent upon physiological rather than specific 
reasons ; and then we must remember that mercury is not 
always indicated in syphilis, and is useful in some condi- 
tions, but harmful or useless in others. It should not be 
used in the initial stage. As a rule, the primary sore, per 
se, is of but slight importance, and is serious only on ac- 
count of its sequehe. If it is not complicated by improper 
treatment and dirt, and remains free from phagedenic ulcer- 
ation and of diphtheritic inflammation, it would get well of 
itself without recourse to any treatment, and therefore it is 
best to confine ourselves at this stage to the simplest things 
possible. Although the books make the diagnosis between 
the chancroid and the initial lesion an easy matter, in reality 
it is frequently quite difficult, especially in the mixed sore, 
where, as is often the case, we have to deal with both the 
chancre and the chancroid ; and, until we are quite sure of 
the true character of the affection, we should abstain from 
the administration of mercury, for in the chancroid it causes 
more or less irritation, and is of no benefit to the patient. 
Even when the diagnosis of the initial lesion is certain, it is 

* Read before the Clinical Society of the New York Post-Graduate 
Medical School and Hospital, March 7, 1885. 



August 1, 1885.] 



STURGTS : SYPHILIS. 



121 



best not to commence the administration of mercury for 
some little time, as it prevents the subsequent development 
of the diseftse, and the maculae do not appear at the end 
of the sixth to the eighth week, or at the end of the forty- 
two davs, and the surgeon is consequently left in doubt as 
to the correctness of his diagnosis. Delay in the adminis- 
tration of the mercury is not detrimental to the patient's 
future progress, and therefore, unless he be married and 
rapid healing a necessity, only the simplest treatment for 
the initial lesion should be employed. Water, lycopodium 
powder, bismuth, or even a piece of cotton or charpie, to 
prevent the friction of the mucous surfaces, is all that is 
required. When further symptoms develop, however, mer- 
cury should be resorted to, and its use should be continued 
through each successive stage. The iodide of potassium is 
useless at the beginning of the disease, and, in fact, its use 
only grew up from an effort to compromise between doing 
nothing and the administration of mercury, which, from its 
abuse in past years, had fallen into disrepute ; but it can 
only be useful as an adjuvant, and not as a substitute. 

That form of mercury should be used which is the sim- 
plest and which produces the least disturbance in the sys- 
tem. The chlorides and the iodides are more apt to pro- 
duce toxic symptoms than other forms. It was observed, 
during my service in the Charity Hospital, that the patients 
who were taking the simple blue pill showed a tendency to 
ptyalism after a meal of salt meat, the salt apparently serv- 
ing to form the chloride. It is no longer considered ngces- 
sary to touch the gums, and any symptoms of its toxic 
effects upon the salivary glands, the gastro-intestinal tract, 
or other portions of the body, should be avoided, and, before 
their appearance, the treatment should be suspended or 
changed. 

The simplest form of mercury is the blue mass, two 
grains of which can be advantageously combined with one 
grain of iron or quinine, thereby producing a tonic effect. 
In truth, mercury is itself tonic when administered in small 
doses, as it increases the number of the red blood-corpus- 
cles ; and in syphilis we have to deal with both physical 
and mental anaemia, the number of the red corpuscles being 
diminished while the number of the white is increased. 
Although mercury in small doses increases the richness as 
well as the number of the red corpuscles, in large doses, the 
effect is quite the opposite. While the administration of 
the mercury by the simple blue pill is probably the best, 
we must not discard the iodides and the chlorides entirely, 
as the former is quite useful in the latter stages of the dis- 
ease. Where there is a tendency to ulceration of the throat 
the bichloride is of use, but the gastric and salivary symp- 
toms must be carefully watched during its administration. 
Calomel is a treacherous preparation, for often, when the 
patient seems to be doing well under its administration, 
there is a sudden and unexpected explosion of hydrar- 
gyrismus. 

The administration of the mercury should be continued 
until the symptoms have entirely disappeared, when it may 
be suspended until the development of some fresh compli- 
cation; hence the treatment of the affection under consider- 
ation is largely on the expectant plan. Relapses often 



occur, but, if treatment is immediately resumed, they be- 
come milder and milder until they cease entirely and the 
patient may be pronounced cured; but whether the disease 
is entirely eradicated the future only can decide. 

This is not very satisfactory, it is true, but, in the pres- 
ent state of our knowledge, nothing more definite can be 
stated. If, however, I were to be asked whether the con- 
dition was curable, I should reply in the affirmative. 

The iodide of potassium should be given, owing to its 
prompt action, whenever there is ulceration about the 
mouth, nose, throat, or parts of the body where there is 
danger of any disfigurement ; but we should not depend 
entirely upon this drug to effect the cure, as it is not so 
positive or so well borne as the mercury. It will often be 
noticed that, when the iodide has been given to promote 
cicatrization, while the process will proceed rapidly for a 
time it will at last be arrested, and the mercury will have 
to be resorted to to complete the process. Small doses of 
the iodide are useless, and when it is indicated it should be 
given promptly and in increasing doses, until the disap- 
pearance of the symptoms or the advent of toxic conditions 
compels its abandonment. It is very readily absorbed and 
as readily eliminated, and we have no knowledge of its 
action which can account for its rapid passage through the 
blood. We do know that while a dose of ten or fifteen 
grains will do little or no good, one of forty or fifty grains 
will be followed by an amelioration of the symptoms; yet 
so rapid is the elimination that it is not likely that more 
is absorbed in the one case than in the other. 

The treatment in skin lesions must be continued until 
not only the eruption but the staining has entirely disap- 
peared, leaving only the scar, which is indelible, and is one 
of the few results of this disease that can not be removed. 

The initial lesion sometimes leaves a scar, and atrophy, 
with a depression and whitish scar, often occurs after gum- 
mous infiltrations, whether in the bone or elsewhere. Some 
cases do not tolerate either mercury or the iodide, and this 
is notably true of those cases which are phagedenic from 
the beginning. Sometimes it is best, owing to the consti- 
tutional debility from excesses of various kinds with which 
these patients suffer, to institute a tonic and hygienic treat- 
ment before having recourse to the mercury or the iodide. 
The iodide of iron is especially useful in these cases, 
although the citrate and potassio-tartrate are well borne. 
Cod-liver oil may also be administered. 

Some patients may recover without the use of mercury, 
but it is not safe to omit its administration, for we can 
never tell how the disease will end. Mercury, too, is our 
best remedy for this condition, and it would therefore be 
indefensible to withhold it and to subject the patient to 
the consequent risk, especially as the dangers from its effects 
are less than from the effects of the disease, and the number 
of recoveries without the mercurial treatment is too small 
to build a theory upon. Besides being given internally, 
mercury may be administered by inunction, fumigation, 
the bath, subcutaneous injection, and by suppositories. 
The results of the inunction are comparatively favorable 
and it has the advantage of leaving the stomach for what it 
lis intended — namely, food and drinks, and not for drugs' j 



122 



STUROIS: 



SYPHILIS. 



[N. Y. Mbd. Jock., 



but is uncleanly, and, while it is used quite extensively 
in foreign countries, Americans will not stand it — they 
prefer to drench their stomachs rather than soil their 
skin for five minutes. The old method was to rub in the 
ointment in different parts of the body consecutively, first 
the arms, then the legs, and then the back. An objection 
to this method is that in delicate skins it will produce an 
eczema, and that it soils the linen beyond redemption, so 
that in private practice it can scarcely ever be used. A 
method which is not so objectionable is, after a hot foot- 
bath, to apply the ointment to the soles of the feet ; woolen 
stockings should then be worn, and then every step will rub 
the ointment in. There is no discomfort, the feet are not 
cold, there is no blistering of the skin, and absorption 
readily occurs. It should be applied every alternate night 
for a week or ten days; then it should be suspended for a 
like period. Iodide of potassium should be given when 
needed, thus constituting the mixed treatment. 

The two remedies combined in the same prescription 
are given by some practitioners, but this is not advisable, 
as it prevents the increase of one of the ingredients with- 
out the increase of the other. It is better to give them 
separately — the iodide in the saturated solution, which 
contains about three fourths of a grain, or practically one 
grain to the minim, largely diluted with an alkaline mineral 
water, after meals, never on an empty stomach. The prot- 
iodide or the biniodide may be given in pill form. 

A mercurial bath may be given once or twice a week, 
according to the strength of the patient. Lamps are sold 
for this purpose. The patient is placed on a cane-bottomed 
chair, stripped, and covered with a blanket, outside of 
which is a macintosh. A lamp, having a gutter for water 
and a cup containing mercury, is placed under the chair 
The patient is left in this vapor until after the mercury is 
completely volatilized and he has had an opportunity to 
cool off somewhat, when he should be wiped off and put 
to bed for two or three hours, as in the Turkish bath. The 
best time for the administration of these baths is at night. 

The hypodermic administration of mercury is now about 
abandoned. When it is employed, a combination of corro- 
sive sublimate or of calomel and albumin is used. It is 
very inconvenient, however, as it necessitates frequent visits 
to the physician, and the pain and discomfort to the patient 
are very considerable. In large bodies of men, as in an 
army or navy, the first objection would not be applicable, 
and the method might be found of use. 

The treatment by syphilization remains to be considered. 
This method depends upon the same theory as vaccination, 
but is subject to the difficulty of the absence of a dilute 
virus, and that we are not able to predict the future of the 
syphilized person. The most recent prominent advocates 
of this theory were Boeck and CEwre, of Christiania. 
When Dr. Boeck was in this country, Dr. Bumstead al- 
lowed him to use the wards of Charity Hospital for the 
demonstration of the theory, and I had an opportunity of 
personally observing the method, but I received an unfavora- 
ble impression from the start, from the fact that the doctor 
made no distinction between the chancroid and the syphi- 
litic sore. Both were syphilis to him, while to me they 



were two very different things, and so I concluded that 
something was "rotten in the state of Denmark." The 
method of treatment was extremely disagreeable, and the 
fact that many of the patients who were subjected to it ran 
away — which was remarkable, as the class that frequent 
Charity look upon it as a summer home— attests how much 
they must have disliked the application. Three sets of 
inoculations were made each time : first, in the right breast, 
and from these matter was taken- for another set, which 
were called the daughter sores, and then matter was taken 
from the last to form the granddaughter set, and then still 
another group, called the great-granddaughters, beyond 
which he did not go. There were usually six or seven of 
these open at a time, and the discomfort was very consid- 
erable, so that many said they would rather have the dis- 
ease than be subjected to the cure, and left the hospital. 
From this circumstance it may perhaps be said that the trial 
was not complete, but the non-discrimination between the 
chancre and the chancroid would have entirely vitiated the 
result. 

As at present all diseases are being caused by bacilli, 
syphilographers are looking for the discovery of such a cause 
for this disease. No tissue is exempt from the inroads of 
the disease. When it attacks the eye, the result may be 
very serious, and we can not be sure that it will not invade 
the deep parts and result in blindness. The earlier eye af- 
fections are not so serious as the later, for in this disease 
there is a tendency toward resolution, while in the later 
affections this tendency docs not exist. Atropine is the great 
remedy in syphilitic iritis, and at one time the ophthalmolo- 
gists relied upon it alone for the treatment ; this is, how- 
ever, a mistake, for, while the mild case of iritis, like the 
mild case of syphilis in other tissues, will get well without 
recourse to mercury, the surgeon should not submit his 
patient to the risk of treatment without this drug. Where 
the choroid or the retina is affected, the bichloride is better 
than calomel or blue pill. The ulcerative throat lesions are 
coincident with those of the skin, and, where the skin is 
non-ulcerative, the same is true of the throat. When the 
throat is affected, the bichloride is the best preparation for 
use; locally, a solution of the nitrate of silver should be ap- 
plied for its stimulating and astringent effects. It can not 
be said to be caustic, even when applied in the solid stick, 
as its action is so superficial. The sulphate of copper may 
be used for the same purpose, or the parts may be dusted 
with calomel. Iodoform is good, but the odor is so intoler- 
able that private patients will not allow it to be used. 

The affections of the bones and the nervous system are 
pathologically the same as the initial lesion, but the one 
tends to resolution while the others do not. When nodes 
become soft, resist the temptation to put in the knife, for, 
while it is good for an abscess to be opened, it is bad for a 
gumma, as it admits the air to the bone and necrosis ensues, 
for which operation is hopeless, as no proper sequestrum 
is formed. In the affections of the nervous system the 
remedy should be given promptly and with a free hand. 
The most unpromising cases get well when properly treated, 
but the iodide must be given in doses which seem appalling 
when compared with those beyond which we were warned 



August 1, 1885.] 



J A GOBY: OSMIG ACID IN PERIPHERAL NEURALGIAS. 



123 



never to go when we first began to use this drug. One 
ounce per diem, in divided doses, has to be given frequently. 
Bumstead reports the case of a patient who took his iodide 
ad lib. He became, in fact, an iodide eater. The rule may 
be relied upon that no toxic results will occur until the 
symptoms yield. The remedy should therefore be carried 
to that point and then dropped. Symptoms that laugh at 
fifty will yield to one hundred grains, and the necessity for 
one hundred and fifty or one hundred and eighty grains 
need cause no alarm. Many physicians will refer to fifteen 
grains as a large dose, and look incredulous when a dose of 
fifty or one hundred is mentioned. All practitioners should 
be prepared for the treatment of syphilis, for it often plays 
a not unimportant part where not expected, and is an im- 
portant factor in the diseases of children. In every depart- 
ment of medicine we must be ready to meet it and to expect 
a cure. 

THE USE OF OSMIC ACID 
IN PERIPHERAL NEURALGIAS* 
By GEORGE W. JACOBY, M. D., 

PHYSICIAN TO THE CLASS OP NERVOUS DISEASES OF THE GERMAN DISPENSARY 
OP THE CITY OP NEW YORK. 

When, in 1883, Neuber (G. Neuber, " Ueber Osmimn- 
saure-Injectionen bei periphare Neuralgien," " Mittheilungen 
aus der chirurgischen Klinik zu Kiel," i) published the re- 
sults of the treatment of peripheral neuralgias by hypoder- 
mic injections of osmic acid, it was to be foreseen that, 
owing to the good results obtained, other observers would 
take up the remedy and investigate its action in this regard. 
Such an inquiry was all the more necessary as the number 
of Neuber's cases was so small. The cases were old and 
obstinate ones, and consisted of two cases of sciatica and 
■one of trigeminal neuralgia, which were all cured after ten 
to twenty-four injections. Only in one case was there a 
return of the pain, and this was again relieved by the same 
mode of treatment. The treatment of neuralgias is fre- 
quently so unsatisfactory that it is well to have at our com- 
mand a great many remedies, any of which offer a hope of 
success. For this reason it becomes our duty to examine 
into remedies which are supposed to exert an influence upon 
this affection, whether that remedy a priori seems rational 
or not. Notwithstanding the small number of cases detailed 
by Neuber, the result attained was so good that Eulenburg 
("Die Osmiumsaure-Behandlung bei periphiiren Neural- 
gien," " Berliner klinische Wochenschrift," 1884, p. 99) 
put the remedy to a fair test. He reports and tabulates 
twelve cases upon which he tried the remedy. The nerves 
affected were various ones of the upper and lower extremi- 
ties of the body and of the head. He chose the fresh and 
not extraordinarily severe cases. The duration of treat- 
ment varied from one to six weeks, and the number of 
injections in the different cases was from three to sixteen. 

In a foot-note to his article he says that since then he 
has treated seventeen more cases, and of these four were 
cured — two sciaticas, one lumbar, and one intercostal neu- 
ralgia. The twelve tabulated cases are as follows : 

* Read before the American Neurological Association, June 17, 
1885. 



No. 



10 
11 

12 



Sex, age, etc. 



35 y., male 
machinist. 

43 y., male 
merchant. 



65 y., 
female. 



44 v., female 
32 y., 
female. 

29 y., 
female. 
49 y., 
female. 

30 y., 
female. 

47 y., 
female. 

40 y., male, 
laborer. 
53 y., 
female. 

49 y., 
female. 



Disease. 



Right - sided sciatica ; 
fresh case. 

Right lumbo-sacral neu- 
ralgia (affection of n. 
cutan. femor. ext. and 
post.), to a slight ex- 
tent also left-sided. 

Left neuralgia brachia- 
lis (" neuritis " of 
single arm nerve- 
trunks) ; fresh case. 

Right sciatica. 

(Epilepsy) right brachi- 
al neuralgia. 

Left trigeminal and oc- 
cipital neuralgia. 
Left trigeminal (Ramus 

u 

Bilateral neuralgia of 
the (lower) intercostal 
nerves ; fresh case. 

Left occipital and cer- 
vico-brachial ; fresh 
case. 

Bilateral sciatica ; old 
case, recidiv. 

Right lumbo-sacral neu- 
ralgia ; old case. 

Multiple (universal) neu- 
ralgias, gouty rheu- 
matic basis. 



Total 
no. of 
injec- 
tions. 



10 



4 

10 

14 



Result of treatment. 



Cure. 

Improvement, but no 
cure ; therefore, gal- 
vanic treatment em- 
ployed. 

Cure. 



Cure. 

Only slight improve- 
ment; bromides and 
galvanism. 

No change ; therefore 
change of treatm'nt 

No chauge ; therefore 
change of treatm'nt 

Improvement slight, 
result not satisfac- 



tory. 
Improvement ; 
galvanism. 



later, 



No change ; change of 

treatment. 
No change ; morphine 

injections also had 

no effect. 
No change ; other 

modes of treatment 

also without effect. 



According to this set of cases, then, the result is not 
very encouraging. In twelve cases there were only three 
cures, four cases were more or less improved, and five cases 
were not influenced at all by the treatment. The three 
cured cases were fresh ones; the unaffected ones were old, 
complicated or multiple. After this publication I began to 
make use of this remedy, and should not now publish my 
observations were it not for reports which have since then 
appeared, and which certainly show us that we have in 
osmic acid a valuable remedy for the treatment of certain 
cases of neuralgia. 

Dr. A. Wolfler, in a report from the surgical clinic of 
Professor Billroth (" Wiener medizinische Wochenschrift," 
1884, p. 1495), reports eight cases, which may be tabulated 
as follows : 



No. 



Sex, age, etc. 



Male, 42 y. 

Male, 50 y. 
Male, 21 y. 

Male, 42 y. 



F'male,56y, 
F'male,62y. 

Male, 67 y. 

Female. 



Disease. 



Right sciatica, three 
years' standing. 

Sciatica, ten years. 

Sciatica ; fresh case, 
three weeks. 

Sciatica, since one 
month. 

Left sciatica, one year. 
Trigeminal neuralgia, 

all three branches. 
Trigeminal neuralgia. 

Trigeminal neuralgia, 
Ramus III. 



Total 
no. of 
injec- 
tions. 



16 

6 
1 



13 

2 

10 



Result of treatment. 



Cure ; no relapse af- 
ter four months. 

Very much improved. 

Cure ; no relapse af- 
ter three months. 

Cured, with exception 
of a small painful 
point in calf of leg. 

Cure. 

Cure ; no attack in 
four months. 

Improvem't ; relapse 
after a few months. 

Improved; still un- 
der treatment. 



This report is so encouraging, and in such contrast to 
Eulenburg's, that it necessarily requires confirmation by 
other observers. Of eight cases reported, we have five 



124 



JACOBY: OSMIG ACID IN PERIPHERAL NEURALGIAS. [N. Y. Med. Joub., 



cured, one improved but relapsed, one improved very much, 
and one improved but still under treatment. In eight cases 
not a single absolute failure. 

James Merces (" Osmic Acid in Sciatica," " Lancet," 
1885, p. 58) seems to have had just as much success. He 
does not give any details of his cases, but says that he has 
tried osmic acid in eighteen cases " which have resisted all 
other known methods of treatment." The ages of the 
patients varied from eighteen to sixty -five. In twelve cases 
he gave absolute relief for a period of three weeks, the 
patients then leaving the hospital. In these cases the 
number of injections varied from one to four. In six he 
gave temporary relief. 

The manner in which I treated my cases was as follows: 
I made use of a 1-per-cent. solution of osmic acid in water, 
and of this 0-50 to 1-00, equal to 0-005 or 0-010, of the acid 
was injected. In a few cases less was used, but very rarely. 
The preparation was that known as osmium tetroxide, OS 0 4 , 
commonly known in histological research as osmic acid. 
The preparation known as hyperosmic acid, which was used 
by Neuber and others, is probably the same. According to 
the best treatises on chemistry, such a combination does 
not exist, as no mention is made of it. The solution, when 
exposed to the light, rapidly becomes decomposed, turning 
dark and ultimately quite black. Eulenburg says that it 
can nevertheless be used in this condition, but my experi- 
ence has convinced me of the contrary. I consider it en- 
tirely inactive when in this state. For this reason it should 
be dispensed only from a dark bottle, and a small quantity 
only ordered at a time. I have never prescribed more than 
20-00 of the solution, this quantity serving for about forty 
injections. The injections were always made as near as 
possible to the point of severest pain and into the con- 
nective tissue surrounding the affected nerve. The pain 
caused by the injection is in many cases exceedingly severe, 
producing a stinging, burning sensation which generally 
follows the course of the nerve. This pain, however, rarely 
lasts long, generally subsiding after a few seconds. Occa- 
sionally, also, local changes are produced, such as swelling 
and puttiness over the seat of puncture, and in many cases I 
have seen a hard, circumscribed thickening of the skin and 
connective tissue produced in consequence of repeated injec- 
tions, which only disappeared after days. There is no dis- 
coloration produced by the acid except, perhaps, a single 
black spot where the needle was introduced. The action 
is a purely local one, no constitutional symptoms whatever 
being produced. The experiments of Dr. E. Fraenkel 
(" Ueber parenchymatose Ueberosmiurasaure-Injectionen," 
"Berliner klin. Wochenschrift," p. 234, 1884) cast some 
light upon the action of osmic acid upon living tissues. In 
three animals he made injections of a 1-per-cent. aqueous 
solution of the acid, injecting 0 - 50 to 1*00. The point of 
injection was, in all three animals, the thigh, as near as possi- 
ble to the point of exit of the sciatic nerve through the fora- 
men. The number of injections made was, upon the first ani- 
mal, four; upon the second, six ; and upon the third, seven. 
Upon the second animal after death, which took place 
twelve davs after the last injection, and sixteen days after 
the first one, the condition found was as follows : Upon re- 



moval of the skin, the superficial fascia and the perivascular 
and intermuscular connective tissue were found to be the 
seat of diffuse black discoloration. The muscles upon the 
back of the leg and thigh were atrophied. The sciatic 
nerve was found to have retained its normal appearance for 
only half a centimetre below its exit from the pelvis. Below 
this point it was colored black, imbedded and intimately 
adherent to the connective tissue. 

This condition is found as far as the knee, from where 
the peroneal nerve may be followed as a clear white cord. 
Microscopically, the sciatic nerve above the seat of lesion 
showed normal fibers. A piece of nerve taken from below 
this point showed nerve -fibers distinctly colored black, 
their structure being completely retained. The fibers situ- 
ated more internally, which were not discolored by the acid, 
were mostly changed, the myelin balled up and granular, 
and, in another branch, fatty degeneration was noticeable. 
In those parts of the muscle which were directly affected 
by the acid an exceedingly severe interstitial myositis was 
developed. The condition found was, in general terms, a 
parenchymatous degeneration of many nerve-fibers, and in 
the muscles a parenchymatous inflammation of the con- 
tractile substance, with atrophy. It is very interesting in 
this experiment to know that osmic acid produces the same 
discoloration upon the living nerve-fibers as it does upon 
the dead ones. Whether this discoloration can have any 
influence upon the action of the nerve can not be answered 
until our knowledge of the transmission of nerve-force is 
more positive than it now is. 

If various branches of a nerve are affected, it is neces- 
sary to inject over each painful branch. These cases will, 
however, be found to be mostly intractable ones. Certainly 
the results are better in those cases in which the pain is 
localized over a single branch. The nerves of the skin do 
not appear to be at all affected by the injections, and no 
amesthetic action was discernible in any of my cases. Of 
the cases under my treatment, and of which I have made 
notes, I shall only give three in detail. The first two, cor- 
responding to Nos. 1 and 2 of the table, are taken as ex- 
amples of the mode of treatment. The third, which is No. 
8 in the table, is given for reasons which will become evi- 
dent when the case is read. 

Case I. — A. S., aged twenty-six years. Had been suffering 
for two years, and had been under my treatment for a right 
sciatica since February, 1883. The pain started from the upper 
part of the thigh and radiated downward to the heel. Pain 
upon pressure over the entire course of the nerve. The pain 
was so intense when he first came to me that he was unable to 
sleep at night, and could obtain a little rest only when under 
the influence of morphine. After six months' galvanic treat- 
ment he felt well enough to discontinue treatment, but, after a 
lapse of two weeks, the pain was as severe as ever, and he 
again came for relief. This time galvanism, massage, morphine, 
and the actual cautery were all tried, but in vain. Thus, six 
more months were passed, until I read Eulenburg's article in 
the "Berliner klinische Wochenschrift." I then made an injec- 
tion parenchymatously over the sciatic nerve, between the tro- 
chanter and tuber ischii, injecting half a grain of the solution. 
These injections were repeated three times a week. The first 
injection was so painful that, notwithstanding all he had already 



August 1, 1885.] 



J AGO BY: OS MIC ACID IN PERIPHERAL NEURALGIAS. 



125 



undergone (actual cautery, etc.), he refused to continue the 
treatment. The injections were all attended with more or less 
pain. After the sixth injection the pain had ameliorated to 
such an extent that he was able to sleep the entire night. In- 
jections kept up. After the sixteenth he was entirely free, and 
has remained so up to date. 

Case II. — T. L., male, aged forty-eight years. Came under 
treatment in May, 1884. Right sciatica, since six year*. Had un- 
dergone, besides the usual modes of treatment, also an operation 
for stretching of the sciatic, but all without relief. Injections 
were made in the same manner as in the preceding case. The 
injections always caused considerable pain, but at no time were 
they unendurable. A translation of parts of a very long letter, 
written in German and dated April 1, 1885, will give a good 
idea of the result attained. He begins: "After I had spent 
months at a time in hospitals during the last six years, and had 
ultimately sacrificed everything in order to regain my health, 
a physician in Newark, after a thorough examination of my 
case, gave me the following advice." 

The essence of this advice was that, as a last resort, he 
should try the osmic-acid injections, for which purpose he was 
referred to me. He then goes on to say : 

"The result of the two to three weekly injections is a re- 
markable one. I can walk very well, but not for a long period 
of time. I can sit, lie down, sleep — all without any pain what- 
soever; but, on the other hand, I can not stand still. This 
causes pain. But I believe that this also will change in time." 

This patient received in all twenty injections. He had been 
suffering from a sciatica whicli disabled him from performing 
any of the necessary acts of life. He could not sleep, he could 
not stand, lie could not walk or sit. The only position in which 
he enjoyed comparative ease was stretched out upon his back, 
and thus he spent the greater part of six years. The result, to 
say the least, was certainly encouraging. 

Case III. — Female, aged forty-five years. Seen in consulta- 
tion April 12, 1884. Left cervico-brachial neuralgia. Princi- 
pal seat of pain over the radial in the arm. The pain had ex- 
isted for two years, and was probably the result of a periar- 
thritis of the shoulder. Every remedy that had been suggested 
had been tried, but without result. I recommended a trial of 
osmic-acid injection, and made one myself over the musculo- 
spiral nerve. I heard nothing more of the case for a fortnight, 
the attending physician having promised to continue the sug- 
gested plan of treatment. After the lapse of that period of 
time, on April 2Gth, the physician called upon me and told me 
that the case had progressed favorably until three days prior to 
his visit. The pain had gradually decreased, and prospects of 
entire recovery were fair. 

At the time mentioned he made the sixth injection in the 
usual place. The patient complained at once of intense pain 
radiating downward into the thumb and forefinger. The pain 
at previous injections had been merely nominal. A few hours 
after that she called again and said that she had a feeling of 
numbness in the first fingers and along the outer border of the 
arm. The following morning the physician called upon her 
and found a well-marked classic, radial paralysis. The patient 
had during the night slept with her arm thrown backward 
under her head, and the doctor concluded that he had to deal 
with a common case of radial paralysis due to pressure. 

To me the case was not so clear. The sudden severe 
pain along the course of the radial after the injection, and the 
advent of anaesthesia soon after, inclined me to think that 
the paralysis was due to the injection itself. This view has 
since then been strengthened in my mind through the pub- 
lication of Arnozan (" Des nevrites consecutivcs aux injec- 



tions hypodermiques d'ether," " Gazette hebdomadaire de 
med. et de chirurgie," January 9, 1885). 

In this article Arnozan calls attention to the occurrence 
of neuritis following hypodermic injections of ether. He 
says that in 1881 he accidentally produced paralysis in four 
cases after injections of ether. In 1883 he saw another 
case together with M. Salvat, and in 1884 M. Charpentier 
and M. Barbier published a case of neuritis of the sciatic 
due to the same cause. In all he publishes seven cases. 
Of these, six are paralyses of the extensors of one or both 
hands, due to injections into one or both forearms. The 
advent of paralysis was immediately consecutive to the in- 
jectiou except in one case, in which the interval between 
the last ether injection and the occurrence of the paralysis 
was nine days. Frankel, in the article already referred to, 
in the clinical part, says of the experiment upon the second 
animal : " After the third injection a complete motor and 
sensory paralysis of the foot was developed, and upon the 
third animal a paresis also occurred." 

In the case of our patient a doubt as to the cause of 
the paralysis is certainly permissible, especially as the pa- 
ralysis was not noticeable until the day after the injection, 
and then may have been due to pressure during sleep. But, 
in view of these two publications of Arnozan an'd Frankel, 
I feel more inclined to ascribe its production to the osmic 
acid. 

My cases — eighteen in all, including the three already 
given — have been tabulated as follows : 



No. 


Sex, age, etc. 


Disease. 


Total 
no. of 
injec- 
tions. 


Result. 


1 


Male, 26 y. 


Right sciatica, old case. 


16 


Cure. 


2 


Male, 48 y. 


Right sciatica, old case. 


20 


Cure. 


3 


Female, 


Left trigeminal, three 


3 


Improved, but gave 




50 y. 


years' standing. 




up treatment. 


4 


Female, 


Left crural neuralgia, 


5 


No change. 




35 y. 


fresh case. 






5 


Female, 


Right brachial neural- 


10 


Cure. 




30 y. 


gia, old case. 






6 


Male, 37 y. 


Bilateral sciatica, old 


6 


No change, examina- 






case. 




tion of urine, sugar, 










diet and opium, re- 










lief. 


1 


Female, 


Left trigeminal, old 


3 


Improved. 




60 y. 


case. 






8 


Female, 


Cervico-brachial, old 


6 


None. 




45 y. 


case. 






9 


Female, 


Cervico-brachial, old 


12 


Cure. 




37 y. 


case. 






10 


Male, 29 y. 


Right sciatica, old case. 


18 


Cure. 


11 


Male, 33 y. 


Left sciatica, fresh 


6 


No change. 






case. 






12 


Female, 


Left cervico-occipital ; 


5 


No change. 




65 y. 


also neuralgia of the 


ove 








III. br. of trigemi- 


each 








nal. 


point. 




13 


Female, 


Occipital neuralgia, ra- 


18 


Cure. 




40 y. 


diating pains to the 










shoulder and arm, 










old case. 






14 


F'male,45 v. 


Right trigeminal, R. I. 


4 


No change. 


15 


Male, 30 y. 


Right sciatica, fresh 


6 


No change; afterward 






case. 




galvanism; relief. 


16 


Male, 39 y. 


Right sciatica, old case. 


17 


Cure. 


17 


Male, 37 y. 


Left sciatica, old case. 


18 


Cure. 


18 


F'male,44y. 


Left sciatica, old case. 


12 


No change. 



These cases, then, analyzed, show us, of eighteen cases, 
eight cures, two improved, and eight unaffected. Of the 
eight cured cases, five were cases of sciatica. All the cured 



126 



ROBINSON: ANTISEPTIC INHALATIONS. 



|N. Y. Mkd. Jock., 



cases, including the sciaticas, were old cases. Of the unim- 
proved cases, eight in number, three were fresh cases and 
two were old. The case marked 8 can not be counted, and 
of 12 and 14 no note is made. 

At any rate, it would seem from these cases that the 
sciatic nerve is the one which is most impressionable to the 
action of this remedy, and that old, inveterate cases present 
a greater chance of success than fresh ones. This is con- 
trary to Eulenburg's experience, and in my cases may be 
misleading, as I used the remedy only exceptionally upon 
fresh cases, in the majority of instances using it only as an 
ultimum refuffium. 

The conclusions justifiable, then, are : 

1. We have in osmic acid a remedy which is of service 
in the treatment of certain cases of peripheral neuralgias, 
and in some cases where every other remedy has failed. 

2. Osmic acid is not an anti-neuralgic, its action is very 
localized, and it frequently fails where other remedies suc- 
ceed. 

3. Its employment is in most cases very painful and not 
altogether free from danger. 

4. In view of Case 8, it is dangerous to implicate a 
motor nerve in the injection. 

ANTISEPTIC INHALATIONS. 

By BEVERLEY ROBINSON, M. D. 
( Concluded from page 65.) 
In my first trials of antiseptic inhalations I made use of 
Kinnicutt's inhaler, which, I believe, was patterned after 
that of Roberts. The inhaler I now employ is slightly 
modified by Ford from Yeo's inhaler, so that the sponge is 
held by two folds of the perforated zinc-wall, instead of 
by strings which originally held it in place. I believe the 
inhaler, as I am now using it, could be perfected in the fol- 
lowing ways: 1. The holes in the zinc-plate to be made 
larger, and thus allow the air to pass through the sponge 
more freely. 2. The posterior half of the inhaler not to 
be perforated at all, but to consist of one uniform piece on 
either side. In this way there would be a stronger direct 
current through the sponge with each inspiratory effort of 
the person inhaling. 3. A double-valve arrangement, to 
be placed so as to allow the vapor to pass from the sponge 
into the respiratory tract during inspiration, and also to per- 
mit the expired air to pass directly out from the inhaler with- 
out repassing through the sponge. With these modifica- 
tions properly made, I am satisfied, in certain cases, that the 
inhaler could be worn almost continuously day and night, 
and sometimes with great benefit to the patient. The 
general treatment followed by my phthisical patients was : 
1. Malt and cod-liver oil. 2. Compound syrup of the hy- 
pophosphites. 3. Iron and arsenic. To the use of one of 
these mixtures, stimulants, powdered meat, digitalis, and 
quinine were occasionally added. Counter-irritation by 
means of iodine, Corson's paint (iodine, croton-oil, and 
ether), or fly-blisters, was made whenever it seemed indi- 
cated. In many cases one of these treatments had already 
been faithfully carried out before the patients came under 
my care, and ordinarily, I regret to add, with anything but 



promising results, in so far, at least, as the rational symp- 
toms of disease were concerned. Of course, with respect 
to the physical conditions of the lungs previous to the 
time when I first saw them I could only form a probable 
judgment, and I inferred simply that as the symptoms of 
disease had not notably improved, so the alterations of 
structure had doubtless not retrograded to any marked de- 
gree. In more than one of my patients the inhalation 
used (fir-wood oil, combined or not with chloroform) eased 
the throat for a long while after using it. In spite of this 
ease to the throat, the cough was not always arrested ; still, 
the inhalation gave a sort of renewed vigor, and the patient 
felt decidedly cheered and encouraged. Sometimes the in- 
halation brings on cough, but not even then does it appear 
to irritate the throat. Usually the expectoration was ren- 
dered much easier; it decreased often in quantity, and, con- 
sequently, there was less cough. While using the inhaler 
one'of my patients had a slight haemorrhage, and was dis- 
posed to believe at first that the inhalation occasioned it. 
Later, and in this same patient, the inhalation (creasote 
and alcohol) caused no irritation whatever of the throat, 
and was worn one hour at a time, and about three or four 
hours in the twenty-four. One patient notably gained sev- 
eral pounds in weight while using the inhaler, and stated 
that he felt stronger and better in every way than he had 
previously. When the inhaler was kept on too long, and 
in those patients who had functional disturbance already of 
the stomach, nausea was occasioned. No inhaling substance 
reduced the quantity of sputa to the same extent as turpen- 
tine, but this liquid was apt to cause dryness and irritation 
of the throat, and was frequently replaced on these accounts 
by creasote and alcohol. Not only were the sputa dimin- 
ished, as a rule, by inhalation, but several times they 
showed manifest changes of color. They also became de- 
cidedly less thick and viscid, and, from being green-looking 
and tenacious, they soon were foamy, like soap-suds, and 
thinner, or showed the aspect of mingled mucus and pus. 
The breathing was also improved on many occasions, and 
the patient could make more exertion without becoming 
flushed and exhausted, or pale and panting. At times the 
improvement of breathing, of cough, in the amount and 
character of the sputa, in the appetite, in strength and feel- 
ing of more lightness and vigor, was accompanied by phys- 
ical changes which seemed to indicate improvement in the 
local condition at the apex, or apices. In one instance, for 
example, I made a note to the effect (and after three 
months' use of the inhaler) that the pleuritic rales which 
had previously existed at one apex during ordinary respi- 
ration had completely disappeared, and the breath-sounds 
had otherwise improved. In other words, they had become 
more vesicular and less harsh, and the expiratory murmur 
less prolonged. 

Owing to the diminution of cough and the decrease in 
the abundance of the sputa, the patient's sleep was not so 
much disturbed — and thus I have found the use of the in- 
haler during the evening, and even at bed-time, was evident- 
ly a greater promoter of rest than cough-mixtures or ano- 
dynes. This was true even when direct examination with 
the mirror had shown that the larynx was red, swollen, and 



August. 1, 1885.] 



ROBINSON: ANTISEPTIC INHALATIONS. 



127 



inflamed, as indeed evidences were already present of incipi- 
ent laryngeal phthisis. One of these patients stated in em- 
phatic termsthat, although she had taken all sorts of drugs 
for her cough, none of them helped her so much as the in- 
halation. I would not have my bearers misunderstand me 
and believe I am of the opinion that in the oro-nasal inhaler 
we have a panacea for cough and other distressing symp- 
toms of phthisis at the first stage. Frequently patients will 
do well for a time with one kind of inhalation, and we shall 
feel greatly encouraged ; and then, through some exposure 
or imprudence, or indeed by reason of the steady on- 
ward march of the disease, the cough again grows worse and 
other annoying symptoms return with full force — again and 
again to be relieved by some new form or combination of 
inhalation. In one case I employed at different times and 
during many weeks, extending in all over several months, the 
following inhalations : At first, inhalations of eucalyptus, 
then of carbolic acid, iodine and benzoin, later of creasote 
and alcohol, and finally of fir-wood oil, conium, and ben- 
zoin. Each one of these relieved for a time, and afterward 
lost its beneficial, soothing effect. Still, everything consid- 
ered, I concluded I had a means which, contrary to HassaH's 
opinion, was powerful for good, and, despite regrettable 
failures, was more useful in many instances than steam in- 
halations or atomized fluids. In not a single instance was 
I satisfied that the metallic inhaler, when properly em- 
ployed — and by this I mean when the quantity of fluid 
poured upon the sponge and the duration and frequency 
of the inhalation were judiciously regulated — increased the 
cough except in a very temporary manner, or was productive 
of any evident bad results. What I have written in regard 
to the effects of inhalation of vapors of antiseptic fluids in 
pulmonary phthisis at its first stage is almost, if not equally, 
true of phthisis at its second stage, and when the pulmo- 
nary apices give undisputable signs of softening and break- 
ing down. Even under these circumstances cough becomes 
less, expectoration is soon more fluid, and, in consequence, 
more readily raised, and the patients speak of diminished 
difficulty of breathing and improved rest and sleep at night. 
In my cases of fibroid phthisis the patients, after a few 
weeks' use of the inhaler, felt much improved. They could 
use the inhaler half an hour to an hour at a time, and sev- 
eral times a day, without inconvenience, and stated that 
they thought the inhalations helped their cough very much. 
In these cases, also, the sputa diminished notably in quan- 
tity and became more frothy, and lost in great part their 
viscid character. From my limited experience with these 
cases, I am inclined to believe the fir-wood oil is more useful 
as an inhalation than any other liquid employed by me. 

In laryngeal phthisis the cough in one instance was more 
frequent and troublesome at first ; later it seemed to im- 
prove. Certainly the expectoration was looser, although 
more abundant, and no unpleasant sensations were experi- 
enced while inhaling. In one instance the patient increased 
several pounds in weight while under treatment by means 
of antiseptic inhalations. No visible changes in the intra- 
laryngeal condition were noted, although repeated examina- 
tions were made with the mirror to detect, if possible, such 
modifications. The inhalation employed in these cases was 



a combination of one part of fir-wood oil with four parts of 
tincture of benzoin. A point to which I desire to direct 
attention in regard to the use of all inhalations is this : Fre- 
quently inhalations are useful in allaying cough and the 
symptoms dependent upon it, even though it is evident that 
the inhalation does not penetrate below, or even so far as, 
the larynx. This fact maybe explained in two ways: First, 
as is well known, the cough may in reality be occasioned 
by a morbid condition in some part of the respiratory tract, 
preceding the lungs in location, and although the lungs or 
bronchial tubes may also be inflamed. This morbid condi- 
tion may be an elongated uvula, post-nasal catarrh, follicular 
disease of the pharynx, acute or subacute laryngitis, etc. 
Again, in the use of all forms of inhalation, while the sooth- 
ing and modifying effects of it are partly due to their direct 
local application, still there are similar effects produced by 
their absorption by and elimination through the mucous 
membrane lining the parts referred to. A final question in 
regard to phthisis and antiseptic inhalations should here be 
mentioned. Do they destroy the Bacillus^ tuberculosis, or 
do they affect notably its growth or vitality? Personally, 
I have never searched for tubercle bacilli after the oro-nasal 
inhaler had been worn a considerable time, and in which, 
previous to wearing it, these characteristic micro-organisms 
had been found. In one case, however, a careful micro- 
scopic examination of sputa was made by my house phy- 
sician when the patient was known to have evident pulmo- 
nary phthisis as shown by indisputable physical signs. At 
the time the bacilli were first discovered, inhalation of anti- 
septic vapors had not been employed. Several months later, 
and when during the intervening period a metallic inhaler 
had been worn during several hours each day, a second mi- 
croscopic examination of the sputa was made and still 
showed a large number of bacilli. The precise relative 
number of these organisms observed on each occasion is not 
mentioned in the history of the patient, nor is it stated 
whether there was any proof to show that the bacilli had 
less vigor than when first detected. What is known defi- 
nitely is this, viz. : that, although bacilli were present in con- 
siderable numbers at the time of the second microscopic 
examination, the patient herself, both as regards her physical 
condition and her rational symptoms, had evidently much 
improved. How much the improvement was. directly due 
to the use of continuous inhalations it was impossible to 
affirm positively. There was no doubt, however, as to the 
fact that they had been useful and comforting in allaying 
cough, diminishing faucial irritability, and promoting the 
ease of expectoration. 

If other observers be consulted, I am not aware that, up 
to the time of writing, anything more definite can be ob- 
tained in regard to the mortuary effects of inhalation on 
tubercle bacilli than what I have stated. 

Whether or not, therefore, dry-vapor inhalations in c on 
centrated form are able to destroy tubercle bacilli is not yet 
satisfactorily determined. That they are powerful to arrest 
or prevent fermentative and putrefactive changes of the sputa ; 
that they can modify the terminal bronchi and lung-cells so 
that they will secrete less purulent matter for expectoration — 
so much at least results from direct clinical observation and 



128 



ROBINSON: ANTISEPTIC INHALATIONS. 



[N. Y. Med. Jot n. T 



experience. It is also highly probable that continuous dry 
antiseptic inhalations are able to weaken and partly devi- 
talize the infective germs upon which the origin and 
growth of pulmonary phthisis largely depend, according 
to the present state of our knowledge. The manner in 
which this is accomplished is apparently either by direct 
action upon these organisms or indirectly by rendering 
their surroundings and the location where they are deposit- 
ed very unfavorable to their extension or propagation. It 
is perhaps true, and it is certainly conceivable — by reason 
of analogy with other means by which some organic germs 
are killed — that such an effect may be produced by pro- 
longed or frequent inhalations of antiseptic volatile agents 
of moderate concentration, as well as by shorter inhalations 
of very strong vapors. This is a most fortunate circum- 
stance, since it is proved that the continuous inhalation of 
concentrated vapors of antiseptic substances, in any notable 
quantity, is rendered impossible by the intolerance of the 
respiratory mucous membrane to their contact. 

The power -such inhalations may have will depend, in 
my opinion, upon several distinct factors: 1. Upon the form 
and efficacy of the inhaler itself. 2. Upon the substance 
which is used and its strength. 3. Upon the frequency and 
less or greater continuance of the inhalations. 4. Upon 
the stage which the pulmonary phthisis has reached, upon 
hereditary influences, hygienic surroundings, and individual 
vigor of constitution. 

Having already taken up much of your time and atten- 
tion, I shall be brief in my remarks about my other cases. 
In fact, I do not consider those in regard to which I have 
preserved notes as sufficiently numerous to warrant any 
strong affirmations. Still, as my memory serves me about 
several cases of each disease treated by inhalation, in some 
particulars at least, I trust that what I may say has more 
value than would be apparent but for this prefatory state- 
ment. 

A. In laryngitis, acute and subacute, antiseptic inhala- 
tions are decidedly useful. They quiet irritation, lessen 
hoarseness, diminish cough, change the aspect of the in- 
flamed mucous membrane, and, in certain cases at least, evi- 
dently hasten the disappearance of symptoms and the estab- 
lishment of a cure. In one case, in which there were con- 
comitant post-nasal catarrh, pharyngitis sicca, and paresis of 
the tensors of the vocal cords, producing hoarseness, there 
were also^'a red, swollen epiglottis, arytenoid cartilages, and 
ventricular bands." In this case there was moderate cough. 
Still it persisted and caused much mental distress, despite 
various medications internally, and numerous local applica- 
tions of pigments, sprays, and powders. One week after 
inhalation was begun the cough had disappeared complete- 
ly. The larynx was less inflamed, the pharynx was not at 
all glazed, there were little or no frothy sputa, and, indeed, 
the patient was so far recovered that the remedy was 
stopped. This had consisted of ten drops of turpentine, 
used in Khraicutt's inhaler, during five minutes every three 
hours. 

B. In cases of chronic nasal catarrh the following effects 
were noted : A singer, having post-nasal catarrh, hyper- 
trophy of the turbinated bodies, slight pharyngitis sicca, 



and catarrhal laryngitis, secondary to the other affections. 
This patient made use of inhalations of pine-needle oil, and 
soon remarked that these inhalations rendered the discharges 
from her uose, especially anteriorly, very much less. The 
breathing also became notably freer. In fact, after two 
months' use of the inhaler, she had very slight trouble, if 
any, with her anterior nasal cavities. There still remained, 
however, some discharge from the naso-pharyngeal cavity. 
It is only fair to state that in this case, as well as in my 
other cases of catarrh of the nose, I made use, concomitantly, 
of other local treatment as an adjunct. Still, by compari- 
son between the cases of nasal catarrh in which dry-vapor 
inhalations were employed and those in which these inhala- 
tions were not used, although other remedies were made 
use of, I believe that the inhalations were undoubtedly 
beneficial in the manner stated above. In three cases, in 
which marked dysphonia was obviously caused by the ca- 
tarrhal inflammation of the nose, inhalations of benzoin and 
of benzoin and fir-wood oil produced marked benefit to the 
voice and general condition of the throat anoVnose. In one 
case, where the nasal duct had become obstructed by rea- 
son of pituitary hypertrophy, and there was consequent 
epiphora, this symptom, among others, was apparently re- 
lieved in a measure by inhalations, and the swollen mem- 
brane was reduced in thickness. 

C. In subacute and chronic bronchitis, inhalations of tinc- 
ture of benzoin and fir-wood oil — one part of the latter to 
eight parts of the former — after one or several weeks, di- 
minished the cough, expectoration, and hoarseness. Iu one 
instance the patient stated distinctly that the cough was 
stopped by the inhalation. The amount of fluid used was 
10 to 15 drops, one or more times during the day, and the 
inhalation was repeated ten minutes every three hours. 

In a case of chronic dry pleuritis the first few inhala- 
tions produced cough, with expectoration. After a time 
the patient felt convinced that the inhalation was of benefit 
to him. " He coughs less now than formerly, and there is 
much less expectoration." 

In one case of chronic laryngitis there was decided 
improvement after only a few days' treatment. 

In my case of paralysis of the tensors of the vocal cords, 
and in one also of chronic pharyngitis, decided ameliora- 
tion was shown after a time, owing to the use of the per- 
forated metallic inhaler. 

DISCUSSION. 

Dr. F. C. Shattuck, of Boston, said the paper confirmed him 
in certain views concerning antiseptic inhalations which were 
partly preconceived and partly based upon experience. Some 
years ago, when antiseptics first began to be used by inhalation, 
he administered them to certain patients. He found carbolic 
acid to be very disagreeable ; it was difficult to induce patients 
to wear the inhaler containing it. He could not say whether or 
not they were of any benefit, but perhaps he employed the in- 
halatious too strong, and possibly under other circumstances 
the results would have been better. Certainly it was very 
desirable to get something which would simply allay cough. If 
by means of such simple remedies as these inhalations we could 
diminish cough and irritation, we should certainly do our 
patients a great service, and the service was no less if it enabled 



August i, 1885.J 



BOOK NOTICES. 



12£ 



us to dispense, even only to a degree, with the use of opium. 
Dr. Hassall's book upon the subject of inhalations was a very 
interesting one, but his statement of the case seemed pretty 
strong. If one put a few drops of an antiseptic, say of carbolic 
acid, thymol, creasote, etc., on a sponge, and found at the end 
of two hours' inhalation that three quarters of the remedy could 
still be detected in the sponge, certainly the amount of the drug 
which could have effected an entrance into the lung must be 
very small. That, it would appear, was reasonable ground on 
which to distrust this method of treatment. Acting upon these 
observations, Dr. Ilassall had constructed his inhalation cham- 
ber, and it would be interesting to see what would be the prac- 
tical working of it. 

Dr. Boardman Reed, of Atlantic City, inquired of Dr. Rob- 
inson whether he had used ether or cocaine by this method of 
inhalation. It had occurred to him that, inasmuch as these 
agents had been found so valuable in other directions, they 
might also prove valuable when inhaled in allaying cough, par- 
ticularly laryngeal cough. 

Dr. P. Kretzsohmak, of Brooklyn, thought the tables re- 
ferred to only went to show that there had been a change in 
the condition of the sputa after the use of the inhaler. 

Dr. B. F. Westbrook, of Brooklyn, thought the benefit 
which Dr. Robinson had produced with this mode of treatment 
could be referred to two factors: First, the favorable influence 
upon the mucous membrane of the upper respiratory tract of an 
atmosphere kept constantly at the same temperature. This 
every one knew to be a very important matter in irritations of 
the respiratory apparatus. It was known that cough, especially 
when violent, almost always had its origin in the trachea or above 
it, although possibly in the bronchi, and a continuous supply of 
uniformly warm, moist air undoubtedly had a very soothing 
effect upon this part of the respiratory tract. Besides, balsamic 
vapors, which Dr. Robinson had employed, when inhaled even 
in very small quantities and for some time, had a very markedly 
soothing and beneficial effect upon the irritated membrane. It 
seemed to him that the allaying of the nasal and postpharyn- 
geal catarrh, the laryngitis, and the bronchitis, would account 
for all the good results which Dr. Robinson had observed. 
Anything which would give the consumptive rest would in- 
crease his appetite, improve sleep, and prove of benefit to his 
general bodily condition. Furthermore, Dr. Robinson had 
given his patients cod-liver oil, malt, and such agents as would 
improve general nutrition. Dr. "Westbrook did not think that 
irritation at the apex of the lung would be more likely to pro- 
duce cough than irritation of any other portion of the lung. At 
least he knew of no proof of it. Dr. Robinson had mentioned 
congestion and oedema of the base of the lung as not being 
accompanied by cough, but it was also very well known that 
pneumonia of the apex was not accompanied by cough, while 
the withdrawal of a sufficient amount of pleuritic effusion to 
exert considerable influence upon the lung usually led to violent 
coughing. He therefore thought it hardly warrantable to say 
that irritation at the apex was peculiarly liable to produce 
cough. 

The President (Dr. A. L. Loomis) remarked that the ele- 
ment of cough in phthisis was a very large one, particularly in 
the third stage, violent paroxysms occurring as the result of 
pleuritic adhesions. One often saw cases in which the only 
evidence of phthisis was the presence of fine crepitation at 
the apex or some other portion of the lung, and yet the pa- 
tient was a sufferer from the most violent paroxysms of cough- 
ing, without there being apparent physical signs in the bron- 
chial tubes or upper air-passages. His experience with inhala- 
tions had led him to believe that they were of use only so far 
as they acted as anodynes to the upper air-passages. He, per- 



haps, was prejudiced against their use, for his experience with 
them had been somewhat unfortunate. Their use had in a few 
instances been followed by profuse hemorrhage. He would 
not say that the inhalations caused the haemorrhages; he would 
only say that two or three cases, occurring at short intervals, 
had led him to be careful. 

Dr. Robinson, in closing the discussion, said, in reply to Dr. 
Reed's question, that on one or more occasions he had used a 
small quantity of ether as an inhalation, either alone or com- 
bined with balsamic vapors, and he thought it produced some 
irritation, although it was very volatile. Certainly ether very 
generally produced more or less irritation, and it was but natu- 
ral that it should do so in these conditions. He therefore pre- 
ferred chloroform to ether. As to cocaine, he had not supposed 
that it would be of any benefit inhaled, and had not employed 
it. He had, of course, used it as a spray or with the brush in 
troubles of the respiratory tract. As to the susceptibility of 
the upper portion of the lung to irritation and the production 
of cough, of course he could not prove the point positively. He 
had concluded, from examination of the sputa in these cases, that 
they had come at least as far as from the lung structure, and, 
with the physical conditions present, it seemed fair to suppose 
that they came from the air-cells. It had been stated in the 
discussion that benefit from the inhalations was due to allaying 
irritation in the nasal cavities, larynx, pharynx, and trachea. 
He too thought that we should seek to know the real source ot 
benefit derived from our treatment. He had only stated that 
in the use of inhalations we should, as far as possible and with- 
out causing undue irritation of the respiratory tract, make the 
air inhaled as pure as we could. That was what he had endeav- 
ored to do, and he had employed small quantities of the drug 
because large amounts caused irritation. If wealthy persons 
went to piue regions and to the Adirondacks in search of pure 
air, with the expectation of being benefited thereby, it was but 
natural to suppose that the poor of New York city would be 
benefited by placing themselves in a condition approximating 
as nearly as possible the surroundings of such regions. While 
he agreed with the president that in a great many cases pleu- 
ritic adhesions might be the cause of cough in phthisis, yet his 
observation had not led him to believe that they occurred as 
frequently as many authorities had stated. He thought the irri- 
tation often centered in the lung itself, and was frequently al- 
layed by favorable atmospheric conditions reaching the lungs 
themselves. 



|bok flotices. 



BOOKS AND PAMPHLETS RECEIVED. 

The Climate of Canada, and its Relations to Life and Health. 
By W. H. Kingston, M. D., D. C. L., L. R. C. S. Edin., etc. Mon- 
treal : Dawson Brothers, 1884. Pp. 266. 

The Middlesex Hospital. Reports of the Medical, Surgical, 
and Pathological Registrars, for the Year 1883. London : H. 
K. Lewis, 1885. Pp. 544. 

Le Peronospora Ferrani, agent infectieux du cholera, et la 
vaccination cholerique. Par le Docteur Duhourcau (de Cau- 
terets), etc. Avec planche gravee. Toulouse : Edouard Privat, 
lb85. Pp. 23. 

Cholera and its Relations to State Medicine. By S. Oakley 
Van der Poel, M. D., LL. D., etc. New York: The Society of 
Medical Jurisprudence and State Medicine, 1885. 

Miscellaneous Reprints. By James Craig, M. D., Jersey City, 
N. J. 



130 



LEADING ARTICLES. 



IN. Y. Med. Jodb., 



THE 

NEW YORK MEDICAL JOURNAL, 

A Weekly Review of Medicine. 

Published by Edited by 

D. Appleton & Co. Prank P. Foster, M. D. 

NEW YORK, SATURDAY, AUGUST 1, 1885. 



THE INTERNATIONAL MEDICAL CONGRESS. 

"With admirable 8elf-control, the profession refrained until 
after the new committee had done its work from giving vent to 
the widespread indignation that the action of the American 
Medical Association at New Orleans gave'rise to. In the same 
issue in which we gave the proceedings of the New Orleans 
meeting we sharply rebuked its course in the matter of the 
Congress, and shortly afterward the "Journal of the American 
Medical Association" characterized it as "of questionable pro- 
priety." We insisted at the time that the movement for a 
reorganization had its rise in the bitterness of personal disap- 
pointments, and not in any genuine feeling that the original 
committee had acted otherwise than in the true interest of the 
Congress. But, as we have said, the profession at large re- 
served its judgment until after the work of the new committee 
had been made known, although it had all along been difficult 
to see how that committee, practically only a ministerial body, 
could accomplish anything in palliation of the destructive course 
that had been entered upon at New Orleans. Any lurking hope 
of this sort that there may have been was seen to be ground- 
less when the results of the Chicago meeting were learned, and 
the profession in most of the great cities were prompt to ex- 
press their condemnation. So rapidly did the new nominees in 
one city after another — Philadelphia, Boston, Baltimore, Wash- 
ington, and Cincinnati — declare that they would take no offi- 
cial part in the Congress under the new organization that it 
became evident that the undertaking was doomed to ignomini- 
ous failure unless a complete reversal of the New Orleans ac- 
tion could be secured. We have for some time been convinced 
that nothing short of that would satisfy the profession and re- 
store any reasonable hope for the success of the Congress.- We 
have felt, too, that this end was most likely to be accomplished 
by getting as full and prompt an expression as possible of the 
feelings of the profession. Of late it has looked as if these 
withdrawals, which at first threatened to confirm the wreck of 
the Congress, would really lead to the radical remedy we have 
mentioned, and also to the far more important result of lifting 
the American Medical Association out of the low position it 
has brought itself to occupy. 

The new organization still has its defenders, however. They 
are no longer confident, and they have been put on the de- 
fensive; but it is evident that they will not give up their un- 
dertaking until they are compelled to do so. The tenacity of 
their purpose is shown by their latest tactics. Realizing the 
effect that is sure to be produced by a continuance of such 
-action as that taken in Philadelphia and the other cities that 



we have mentioned, and the informal action taken by indi- 
viduals elsewhere, they are now trying to persuade those who 
have not yet declined not to do so. They hold out the consid- 
eration that it is unnecessary and quite out of character for 
a man to decline a position until he has been officially notified 
of his appointment. As the secretary can take his own time 
about notifying the appointees, it is evident that, in case he 
avoided sending out notices, and the appointees could be made 
to take the advice mentioned, they would have the game in 
their own hands. It is nearly a month since the appointments 
were made public, and it seems to us that any of the appointees 
who hesitate to declare their intentions, simply because they 
have not been officially notified, can only be compared to the 
man who, seeing a man drowning, refrained from interfering, 
on the ground that he had never been introduced to him. 

Another device to which they are resorting is that of affect- 
ing to look upon the dissatisfaction that has been expressed as 
not really due to their revolutionary scheme of reorganization, 
but simply to the unpopularity of the secretary, Dr. Shoemaker, 
and it is hinted that that gentleman will be induced to resign, 
with the result of calling back those who have declined, and 
restoring harmony. It is needless to say that nothing could be 
more absurd than the pretense that Dr. Shoemaker's unpopu- 
larity, in case it exists, is at the bottom of the serious action 
that has been taken. It is little short of ridiculous to bring 
forward so paltry a matter as being the cause of so important 
a step. But, even if there were any truth in it, Dr. Shoemaker 
is not the man to allow himself to be cast overboard as a 
Jonah. We must conclude, therefore, that the petty nature of 
ail that can be said in favor of the reorganization augurs well 
for the hopes of those who recognize that nothing but its over- 
throw can save the Congress. 

DEMAND AND SUPPLY AS APPLIED TO PHYSICIANS. 
The constant tendency of our teaching bodies, quite inde- 
pendently of the urging that has come from the profession at 
large, and the striving of the latter, wholly apart from any 
demand on the part of the community, toward improvement in 
medical instruction are as gratifying as they are evident. We 
believe that within certain limits the matter may safely be left 
to these agencies. Therefore we have never looked upon pro- 
posed legislative enactments bearing upon it as quite the pana- 
ceas that their authors have seemed to believe them. We have 
insisted that a uniform standard of the qualification to practice, 
whether high or low, was impracticable under existing circum- 
stances. If too high, it would reduce the number of practi- 
tioners below the force needed in a sparsely settled country; if 
too low, it would not meet the fair demands of the older sec- 
tions. 

That the first of these contingencies is not altogether imagi- 
nary is beginning to be found out even in so compact a com- 
munity as that of England. The "Medical Times and Gazette," 
of London, lately said : " Assuming for a moment, what might 
perhaps claim to be more than a mere assumption, that the 
well-meant strictness of the Medical Council is really cutting off 



August 1, 1885.] 



MINOR PARAGRAPHS. 



131 



the supply of qualified practitioners in poor and distant neigh- 
borhoods, and throwing their inhabitants into the hands of 
quacks and herbalists, who is there to warn the Council of this 
result? " It is doubtless a. source of annoyance to a man who 
has spent all the time and money that could be spent to advan- 
tage in attaining to a thorough mastery of the medicine of the 
present day to be classed by the community only as one among 
little short of a hundred thousand possessors of the degree of 
M. D., and it is no less an annoying and humiliating circum- 
stance that foreign critics almost invariably hold up our weaker 
educational institutions as specimens of what we are able to 
produce. All this is inseparable from the young and unde- 
veloped state of the country, and it should be endured with 
resignation, as a sort of sacrifice to "the greatest good of the 
greatest number." 

It has often been said to our discredit, and often complained 
of by the unsuccessful among us, that the proportion of the 
medical body to the population was far in excess of what was 
to be found in other countries. We have before expressed the 
conviction that this excess had not the same significance that it 
would have in a densely peopled country, and we believe that 
the great numbers of "young doctors turned out" every year, 
as the phrase runs, are not an unmitigated evil. 



MINOR PARAGRAPHS. 

AN INJUSTICE TO A DISTINGUISHED PHYSICIAN. 

The "Medical Times and Gazette" gives a summary of a 
statement by Professor Warlomont, of Brussels, a distinguished 
ophthalmologist, and a man well known for the energy and in- 
genuity he has displayed in the study of animal vaccination, as 
well as for his admirable report on the famous Louise Lateau 
case. The story was published in the " Presse medicale beige," 
and it sets forth the circumstances of an injustice to which Dr. 
Warlomont has been subjected. He has been dismissed arbi- 
trarily from the post of director of the Ophthalmological Insti- 
tute, the only reason given being the fact that the state of his 
health had made it necessary for him to go abroad for a few 
months during the past year, for which he had obtained the 
permission of the authorities. During the thirty years of his 
service he had never before been a week at a time away from 
his post. The managers superseded him by abolishing his office. 
The pension to which he was entitled was refused him on the 
ground that it could only be gained by a person who had at- 
tained the age of sixty-five years. He lacks less than a year of 
having arrived at that age, and it looks as if his dismissal had 
been abruptly and hastily brought about, as our contemporary 
intimates, with the intention of depriving him of this acknowl- 
edgment of his services. 



NEWS ITEMS, ETC. 

The Plymouth Epidemic— The memorable epidemic of 
typhoid fever at Plymouth, Pa., is now announced to have so 
far subsided as to be practically at an end. The relief commit- 
tee has discontinued its work, and the hospital was to have been 
closed yesterday. 

Chicken-pox mistaken for Small-pox. — That unsavory 
suburb commonly known as Hunter's Point, but which rejoices 
in the high-sounding corporate name of Long Island City, seems 



likely to have a suit for damages to defend, according to the 
newspapers, as it is alleged that the authorities ordered the re- 
moval of a man who seemed to have small-pox to the hospital 
on North Brother Island, where it was discovered that he was 
only suffering from chicken-pox. He was kept in the hospital 
eleven days. 

Infectious Diseases in New York.— We are indebted to- 
the Sanitary Bureau of the Health Department for the following 
statement of cases and deaths reported during the two weeks 
ending July 28, 1885 : 



DISEASES. 


Week ending July 21 . 


Week ending July 28. 


Cases. 


Deaths. 


Cases. 


Deaths. 




1 


0 


0 


1 




10 


2 


16 


6 




40 


14 


29 


6 


Cerebro-spinal meningitis .... 


4 


3 


2 


1 




48 


8 


34 


8 




59 


23 


34 


21 




2 


0 


1 


1 



The Health of Connecticut.— We learn from the June re- 
port of the secretary of the State Board of Health, Dr. C. A. 
Lindsley, that the death-rate of ten cities in the State was 16"6 
in 1,000, against 18-6 for the month of May. Hartford and 
Norwich, however, showed 23 - 4 and 20 - 4 respectively. Dr. R. 
M. Griswold, of North Manchester, reports an endemic of quinsy, 
laryngitis, and bronchitis as manifestations of malarial poison- 
ing. 

Sir Guyer Hunter is reported, says the " Medical Times 
and Gazette," to have been selected as a candidate for a seat in 
Parliament. 

Army Intelligence.— Official List of Changes in the Sta- 
tions and Duties of Officers serving in the Medical Department, 
United States Army, from July 19, 1885, to July 25, 1885 : 
Elbeet, F. W., Captain and Assistant Surgeon. Sick leave of 
absence further extended four months on surgeon's certifi- 
cate of disability. S. O. 162, A. G. O., July 17, 1885. 
Strong, Norton, Captain and Assistant Surgeon. Ordered for 
temporary field duty with battalion of 8th Cavalry at Hills- 
boro, N. M. S. O. 34, Headquarters District of New Mexico, 
June 27, 1885. 

Everts, Edward, First Lieutenant and Assistant Surgeon. 
Ordered for duty as post surgeon, Benicia Barracks, Cal. 
Par. 3, S. O. 70, Department of California, July 15, 1885. 
(Modifies Par. 2, S. O. 68, 0. S., Department of Cali- 
fornia.) 

Winne, C. K., Captain and Assistant Surgeon. Ordered for 
duty at Benicia Arsenal, Cal. Par. 3, S. O. 70, Department 
of California, July 15, 1885. (Modifies Par.'2, S. O. 68, C. S., 
Department of California.) 

Society Meetings for the Coming Week : 

Monday, August 3d : Utica, N. Y., Medical Library Association ; 
St. Albans, Vt., Medical Association; Providence, H. I., 
Medical Association ; Chicago Medical Society. 

Tuesday, August 4th : Elmira, N. Y., Academy of Medicine ; 
Buffalo, N. Y., Medical and Surgical Association; Ogdens- 
burg, N. Y., Medical Association ; Hudson County, N. J., 
Medical Society; Hampden District, Mass., Medical Society 
(Springfield) ; Androscoggin County, Me., Medical Associa- 
tion (Lewiston). 

Thursday, August 6th: Society of Physicians of the Village of 

Canandaigua, N. Y. 
Saturday, August 8th: Miller's River, Mass., Medical Society. 



132 



LETTERS TO THE EDITOR.— PROCEEDINGS OF SOCIETIES. [N. Y. Med. Jouh., 



f titers io % debitor. 



THE INTERNATIONAL MEDICAL CONGRESS. 

University op Michigan, July 27, 1885. 
To the Editor of the New York Medical Journal: 

Sir: Please add our names to the list of those gentlemen 
who have already declined to serve as officers in the organiza- 
tion of the International Medical Congress as now arranged by 
the second enlarged committee of the American Medical Asso- 
ciation at their recent meeting in Chicago. In taking this step 
we do not intend to criticise the committee for their action. 
On the contrary, we think that, handicapped as they were, they 
did their work remarkably well. But we do object to the ac- 
tion of the American Medical Association at the New Orleans 
meeting in introducing into the question of the organization of 
a congress for scientific work an element that has no more per- 
tinency to such a purpose than the matter of a man's religion 
or his politics. Very respectfully, etc., 

E. S. Dunster, M. D., 
Henry Sewall, Ph.D. 



THE INTERNATIONAL SANITARY CONFERENCE AND THE 
DISINFECTION OF RAGS. 

To the Editor of the New York Medical Journal : 

Sir: Injustice to ine, I trust that you will publish the fol- 
lowing letter, which I have just written to the "New York 
Times," in your next issue. 

" To the Editor of the 1 Times ' : 

"Sir: In your issue of July 22d, under the heading 'The 
Importation of Rags,' I find the following: 

" ' The frequency with which inaccurate statements have been 
made concerning the disinfection of imported rags is somewhat 
extraordinary. Several days ago the "Times" called attention 
to a letter from Rome, published in a Philadelphia medical 
magazine, which purported to give the report agreed to by the 
Committee on Disinfection appointed by the International Sani- 
tary Conference. The letter in question contained the follow- 
ing clause : 

" ' " V. Disinfection of merchandise and of the mails is un- 
necessary (steam underpressure is the only reliable agent for the 
disinfection of rags — les chiffons en gros)." 

" ' The " Times " suggested that probably the words were in- 
terpolated by the writer of the letter. A few days thereafter 
Dr. George M. Sternberg, the American delegate to the confer- 
ence, and the same gentleman who was employed as an expert 
by Health Officer Smith to make some tests of disinfecting pro- 
cesses in Brooklyn, sent a note to the " Times " denying that the 
writer of the letter had interpolated the words in question. A 
gentleman in this city who is interested in the importation of 
paper stock wrote to Dr. Koch at Berlin for definite informa- 
tion on this point, and yesterday he received a cablegram stat- 
ing that no such words as those quoted in parentheses appear in 
the report of the committee.' 

"The subscriber has nothing to do with the fight between 
the paper manufacturers and the health officers who insist upon 
the disinfection of rags from cholera-infected countries, but 
must request space in the 'Times' to defend himself from the 
grave charge made in the above-quoted paragraph. 

" What the gentleman interested in the importation of paper 
stock wrote to Dr. Koch I do not know, but that Dr. Koch 
should deny that the words referred to are a part of the report 
of the Committee on Disinfectants is incomprehensible, and can 
only arise from some misunderstanding on his part. 



" I inclose herewith a copy of the report of the Committee 
on Disinfectants which was printed in Rome and distributed to 
all of the members of the Conference. The correspondent of 
the Philadelphia medical journal referred to has given a very 
good translation of Article V, which in the original is as fol- 
lows: 

" ' V. La disinfection des marchandises et des colis de poste 
est superflu (La vapeur sous pression serait le seul moyen si on 
voulait disinfecter les chiffons en gros.)' 

"The same wording will be found in the report of the com- 
mittee as adopted in proces-verbal No. 10, page 3; also in the 
Releve des conclusions, page 16. 

"A copy of the proceedings, printed in French and brought 
by myself from Rome, is on file in the office of the Hon. T. F. 
Bayard, Secretary of State, and another copy in that of the 
Surgeon-General, U. S. Army." 

George M. Sternberg, Major and Surgeon, U. S. Army, 

Delegate to International Sanitary Conference. 



fliotcctrings oi £»qu lies, 



AMERICAN OPIITHALMOLOGICAL SOCIETY. 

Twenty-first Annual Session, held at the Pequot House, New 
London, Conn., Wednesday and Thursday, July 
15 and 16, 1885. 

(Concluded from page 105.) 

Two Cases of Congenital Paresis of the External Rectus 

were reported by Dr. Harlan, who also exhibited and described 
Borek's sphero-cylindrical lenses. 

The Removal of a Piece of Steel from the Lens with the 
Electro-Magnet. — Dr. J. L. Minor, of New York, reported a 
case in which the shank of a strabismus- hook was touched to 
an electro-magnet, thus making it a magnet. The extremity of 
the hook was then carried into the lens, and the piece of steel 
at once attached itself to it and was removed. Thirteen days 
later the eye had recovered from the operation. The lens had 
not yet been removed. 

Removal of an Epithelioma of the Eyelid by Applica- 
tions of Benzol and Calomel.— Dr. A. Mathewson, of Brook- 
lyn, reported the case of 0. D., a laborer, fifty years of age, who 
was seen October 3, 1881, with a tumor on the right lower lid. 
This first appeared as a warty growth three years previously. 
Of late it had been rapidly growing, and presented a raw granu- 
lation surface. Careful examination by an expert showed it to 
be undoubted epithelioma. It was treated by frequent dustings 
of calomel, after brushing the surface with benzol. The tumor 
entirely disappeared until a few months ago, when a granular 
spot appeared at one edge of the site of the former growth. 
This disappeared under a renewal of the same treatment. 

Lipomatous Ptosis.— Dr. H. S. Schell, of Philadelphia, re- 
ported four cases of ptosis from excessive accumulation of fat 
in the upper lids. The excessive fat was removed through a 
horizontal incision. The smallest amount taken away was 
thirty-five grains, the largest seventy-one grains. The levator 
regained power in from one to four weeks. In one case it was 
necessary to repeat the operation. 

The Pulsating Variations of Intra-ocular Tension as 
measured by the Manometer. — Dr. Luoien Howe, of Buffalo, 
N. Y., exhibited the double manometer described by Grasser 
and Holzke. In this there was an imperfection in the trocar 



August 1, 1885.] 



PROCEEDINGS OF SOCIETIES. 



133 



which was rather complicated and liable to get out of order. 
An improvement was accordingly suggested in having a stop- 
cock attached to a needle of the hypodermic syringe, and this 
the writer found to serve the purpose much better than any 
other. The animal best adapted to this class of experiments 
was the cat, on account of the deep anterior chamber. 

In the earlier experiments with the manometer it was no- 
ticed that the intra-ocular tension varied with the heart's 
action. In addition to this, the writer called attention to the 
fact that these variations in the pressure as indicated by the 
manometer corresponded to pulsations which could be seen with 
the ophthalmoscope in the vessels in the interior of the animal's 
eye. In other words, if the same thing held in the human sub- 
ject, we must infer that, when pulsation was seen in the interior 
of the eye, there was also a variation of intra-ocular tension, 
-although not enough to be detected by the touch or by an ordi- 
nary instrument. This connection between pulsation and press- 
ure was a demonstration of the cause of venous pulse in the eye 
as explained by Bonders. It was also observed that after the 
introduction of the needle there was at first considerable pulsa- 
tion, but after a short time this ceased, the eye evidently ad- 
justing itself to the unusual condition. The experiments re- 
ferred to were made in the laboratory of Prof. Zunzt, of Berlin. 

The Extraction of Chips of Iron from the Interior of the 
Eye. — Dr. H. Knapp reported nine successive cases in which 
the electro-magnet was .used for this purpose. 

These cases were operated on during the past three years 
and a half. In two the chip of iron was located in the iris, in 
one for two days, causing inflammation, and in the other for 
seventeen years, remaining quiet until receutly. Both were 
successfully removed without injury to the eye. 

In the seven remaining cases the foreign body was in the 
vitreous, had produced cataract, and could not be seen. In 
three cases the attempt to extract them with the magnet failed, 
and the eyes had to be enucleated. In four cases the chips of 
iron were brought forth at the first, second, or third introduc- 
tion of the tip of the magnet. In all these four cases the recov- 
ery was uninterrupted. All four were still cataractous. In two 
the form, size, and tension of the globe were not changed, and 
the perception of light was good over the whole field. In the 
two others the globe was slightly smaller and softer and the 
field of vision defective, corresponding to the wound made for 
the extraction of the foreign body. There was no irritation in 
any of the four eyes as long as they were under observation. 

The Actual Cautery in Destructive Corneal Processes. — 
Dr. Knapp cited a number of cases in which its use had been of 
service, and he considered it a valuable measure. 

Thursday's Proceedings. 

Pneumophthalmos, or Air in the Vitreous.— Dr. W. F. 

Mittendorf, of New York, reported two cases, the first of which 
was that of a young blacksmith who was wounded by a piece 
of iron penetrating the sclera and lodging in the vitreous. The 
foreign body, surrounded by a clot of blood, was found at the 
bottom of the eye. Behind the lens and a little above it, three 
air-bubbles were seen by means of the ophthalmoscope. These 
appeared to be of the size of a small pea, the smallest about as 
large as a rape-seed. They closely resembled the air-bubble as 
seen under the microscope, their centers being bright and the 
outlines well defined, and surrounded by a sharp, black border. 
Their recognition was not difficult. The foreign body could not 
be removed with the magnet, and it was decided to allow it to 
remain. The eye was carefully bandaged, and the day following 
it was found that the air-bubbles had united and were located at 
the posterior pole of the lens, the patient having remained 
quietly on his back some time before the examination. While 



he was in the upright position the air began to rise slowly until 
it reached the upper part of the vitreous chamber. During this 
trip the bubble looked oval and decidedly pointed at its lower 
portion, resembling oil globules as they are seen ascending in 
water. Forty-eight hours after the accident every trace of the 
air-bubbles had disappeared. 

The second case was the result of a drilling accident. Quite 
a large piece of stone or iron had perforated the sclera at the 
lower and outer part of the eye. In the semi-transparent vitre- 
ous an air-bubble of the size of a hemp-seed could be seen dis- 
tinctly. 

In order to determine the exact appearance of air in the 
vitreous, the writer experimented upon rabbits' eyes. Four of 
them had air introduced into the vitreous humor by means of a 
hypodermic syringe, and four were subjected to the introduction 
of oil, also by means of the hypodermic syringe. Nearly all 
these experiments were successful. The difference between the 
air- and the oil-bubble was so marked that they could be readily 
diagnosticated by means of the ophthalmoscope. The latter 
were more highly refractive, heavier in appearance, and the 
contour decidedly darker than the air-bubbles, which were en- 
tirely colorless. 

The conclusions reached by the author were as follows: 1. 
The entrance of air into the vitreous body could occur only after 
a part of the contents of the vitreous chamber had escaped. 2. 
It was favored by the entrance of a foreign body, which made a 
large, gaping, irregular wound of the sclera. 3. In order to 
allow air to enter the vitreous, this must either be quite fluid or 
its anatomical arrangement must have been disturbed by the 
entrance of a foreign body, or the air must have been attached 
to the foreign body and carried with it into the eye. 4. The 
air in the vitreous humor appeared like an air-bubble as seen 
under the microscope ; it was more or less round, highly refrac- 
tive in the center, and had a sharply defined black outline. 
5. Oil-globules in the vitreous presented a similar appearance, 
but they looked heavier and were not perfectly colorless, and 
their outlines were darker; they were also more glittering in the 
center. 6. Air-bubbles would be absorbed completely within 
two or three days; their presence was not a source of great dan- 
ger to the eye. Oil-globules lasted longer, but they were like- 
wise non-irritating. 

A Case of Tubercle of the Iris.— Dr. Myles Standish, of 
Boston, reported the case of a girl, fourteen years of age, who 
came under his observation with an eye trouble which had ex- 
isted four weeks. There had not been much pain or photo- 
phobia. No specific history could be elicited. During the past 
winter the patient had suffered with intense epigastric pain and 
ascites. The iris was attached by its pupillary margin to the 
capsule of the lens, and presented near its ciliary border a 
growth 2 mm. in diameter, pink in color, with small vessels on 
its surface. In the course of a month the growth had doubled 
its size, the conjunctiva and iris remaining perfectly clear. 
Other growths made their appearance, and, after consultation 
with Dr. Wadsworth, the eye was removed at the Massachusetts 
General Hospital. Examination after enucleation show 7 ed the 
vitreous, retina, and choroid to he normal. The lens was some- 
what opaque. The iris was very adherent to the capsule of the 
lens along its pupillary border, and also beneath the entire area 
of the principal growth. The largest mass sprang from the sur- 
face of the iris near its ciliary border, and at its base was 2 - 5 
mm. in diameter and 2 mm. in height. At the top its diameter 
was 4 mm. This was apparently due to the pressure of the 
growth against the cornea. There were three other growths, 
but none of them involved the ciliary body, or even the ciliary 
border of the iris. The microscopical examination showed the 
presence of giant cells and of tubercle bacilli. 



134 



PROCEEDINGS OF SOCIETIES. 



[N. Y. Med. Jock., 



Dr. Knapp had seen growths presenting exactly the same 
appearance which had disappeared under treatment with mer- 
cury, even where there was no evidence of syphilis. He had 
never felt warranted in making the diagnosis of tuhercle in 
such cases, although the presence of the tubercle bacilli in this 
case would seem to confirm the diagnosis. 

A Case of Congenital Coloboma of the Iris, Choroid, 
etc., was reported by Dr. C. J. Kipp. The patient was a woman 
sixty-nine years of age. She was first seen four years ago. 
There were at that time no inflammatory symptoms, but a small 
triangular coloboma of the iris was found exactly in the ver- 
tical meridian. The tension was above normal. The patient 
had never seen with this eye, but it had never given pain. Four 
years later the patient was again seen, and the eye presented 
the signs of inflammatory glaucoma. The pain had prevented 
sleep for many weeks. The eye was enucleated and healed 
promptly. There was also found a large ectasia of the sclerotic, 
and over this the choroid and retina were wanting. The ecta- 
sia extended close to the optic papule. There was also a deep, 
kettle-shaped excavation of the optic nerve. 

Coloboma of the Choroid on the Temporal Side.— Dr. S. 
D. R islet, of Philadelphia, reported the case of a young physi- 
cian who consulted him for asthenopia. There was a consid- 
erable degree of myopia in the left eye. In the right eye vision 
was much diminished. The ophthalmoscope showed a large 
hiatus in the choroid on the temporal side, the depth of which 
was 3 D. There had been no pain. The speaker thought that 
these cases were comparatively rare. 

Gray Degeneration of the Optic Nerve with Abnormal 
Patella Tendon Reflex.— Dr. William F. Norris made an 
elaborate review of the literature of the subject, and gave the 
results of his observations in cases in which the patella tendon 
reflex was increased or diminished. He described three cases 
of gray degeneration associated with tabes dorsalis which had 
come under his observation. While he did not hold that this 
symptom indicated beginning tabes dorsalis, yet it was a danger 
signal calling for rest of the brain and cord, with attention to 
improvement of the general condition. 

A Case of Double Optic Neuritis and Ophthalmoplegia 
from Lead Poisoning complicated with Typhoid Fever. 
— Dr. O. F. Wadsworth reported the case of a boy nine years 
of age who had suffered from obscure febrile symptoms for sev- 
eral weeks, and movements of the left eye had been observed to 
be imperfect. When first seen by Dr. Wadsworth there was 
pronounced optic neuritis in both eyes. The rest of the fundus 
was normal. Vision was much diminished. No lateral move- 
ments of the left eye could be made, and movement downward 
was impaired. The outward movement of the right eye was 
defective. The probable diagnosis was tumor in the region of 
the pons. 

The movements of the eyes became still more impaired and 
vision sank. The boy developed distinct symptoms of typhoid 
fever. The spleen and liver were both enlarged. Lead was 
found in the urine, and the diagnosis of tumor was then aban- 
doned. The treatment was with iodide of potassium. The gen- 
eral condition gradually improved; the neuritis passed into atro- 
phy, leaving too little vision to count fingers. The movements 
of the eyes were completely restored, and the lead disappeared 
from the urine. The cause of the lead-poisoning was found to 
be. the presence of a piece of lead pipe in the cistern from which 
the drinking water was obtained. 

Olive-Oil as a Menstruum for Dissolving Cocaine for 
Application to the Eye. — Dr. Joseph A. Andrews said that 
the plan of dissolving cocaine in oil seemed to insure a longer 
contact of the remedy, and a smaller quantity was required to 
effect anaesthesia — two qualities of special advantage in opera- 



tions on the eye. Neither the salts of cocaine nor those of 
atropine were soluble in olive-oil; but both alkaloids dissolved 
readily in the menstruum without the addition of an acid, it 
being only necessary to expose the solution for a few minutes 
to a gentle heat in a water bath. 

Enucleation of the Eye for Glaucoma precipitating 
Glaucoma in the other Eye.— Dr. David Webster reported 
a case, the patient being a man of fifty-four, the subject of glau- 
coma absolutum. He complained of periodical obscurations of 
vision in the good eye, and there was no limitation of the visual 
field. As he was of dissipated habits, he was advised to live 
properly. A week or two later he returned, stating that he had 
had a worse attack. There was detected an excavation of the 
nerve in the good eye. The glaucomatous eye was now re- 
moved. Two days later acute glaucoma appeared. An iridec- 
tomy was performed, and he recovered in a week or two, with 
no cupping of the disc and no limitation of the field. 

Quinine Amaurosis.— Dr. E. Williams reported two cases. 
In the first case a man took about one ounce in the course of 
four days. This produced total blindness and deafness, but in 
six weeks he could see as well as ever. The hearing had never 
completely returned, although the quinine was taken eight years 
ago. The field of vision was concentrically contracted in both 
eyes. The optic discs were very white, the caliber of the ar- 
teries and veins was reduced, and the smaller capillaries could 
not be seen. 

The second case was that of a boy of fourteen, who had 
received large doses of quinine, the exact amount not being 
known. He was totally blind for four days. When examined, 
the sight was much diminished, the atrophy of the optic discs 
was extreme, and there was great contraction of the field of 
vision. 

A Means of Measuring the Amount of Anaesthesia from 
Cocaine. — Dr. Lucien Howe exhibited the drawing of a kymo- 
graph, which he had used for this purpose. The use of the 
instrument was based on the fact that irritation of a sensory 
nerve was followed by a rise of blood-pressure. The instru- 
ment was connected with an artery, and the conjunctiva was 
irritated. Cocaine might then be applied, and the results on 
the blood-pressure compared. 

Officers for the Ensuing Year.— President, Dr. W. F. Nor- 
ris, Philadelphia; Vice-President, Dr. Hasket Derby, Boston; 
Secretary and Treasurer, Dr. O. F. Wadsworth, Boston ; Cor- 
responding Secretary, Dr. J. S. Prout, Brooklyn. 

New Members were elected as follows: Dr. Charles A. 
Oliver, Dr. Edward Jackson, and Dr. B. Alexander Randall, 
Philadelphia ; Dr. D. Pope Walker and Dr. William 0. Moore, 
New York ; Dr. Frank G. Capron, Providence ; Dr. S. M. Bur- 
nett, Washington ; and Dr. William T. Bacon, Hartford. 

The next meeting will be held at New London, the third 
Wednesday in July, 188(3. 

CLINICAL SOCIETY OF THE 
NEW YORK POST-GRADUATE MEDICAL SCHOOL 
AND HOSPITAL. 

Meeting of March 7, 1885. 

Dr. F. R. Stdrgis in the Chair. 

Syphilis. — The Chairman read a paper on this subject. 
[See page 120.] 

Dr. G. H. Fox did not consider that syphilis was the fright- 
ful disease that the text-books would have us believe. He also 
thought the results of its treatment by mercury much overrated, 
and considered that this drug could be dispensed with without 
involving any risk to the patient. The value of a remedy in the 
treatment of any special disease could only be determined when 



August, 1 1885.1 



PROCEEDINGS 



OF SOCIETIES. 



135 



the opportunities of studying the natural history of the trouble 
had been taken advantage* of, and he did not believe that this 
was the case with the mercurial treatment of syphilis. Many 
persons were, too, greatly adverse to mercury, and therefore it 
had been the custom for a number of years in the New York 
Dispensary to ask the patient if he objected to its use, and if the 
reply was in the affirmative, as it often was, they considered 
that they were authorized in omitting it altogether, taking the 
liberty of thus carrying out an experiment with the consent of 
the individual ; and this practice in his hands had been free 
from bad results. He considered that the average case of syphi- 
lis was benignant in character, and, given average good health, 
previous to the inception of the disease, did not believe that it 
would produce the ravages ascribed to it. He did not care to 
say that mercury was useless in these cases, but thought it was 
better to rely upon tonic and bygienic measures than upon the 
drug alone, and he felt convinced that many patients recovered 
under this mode of treatment. He knew of several old men 
who bad undoubtedly contracted the disease in their youth and 
who had completely recovered without the intervention of mer- 
curial treatment. He also thought that when mercury was used 
the dose should be much smaller than the one usually employed, 
considering that half a grain of blue mass would accomplish all 
that could be gained with one to two grains. The treatment of 
syphilis should no more be based upon a routine plan than the 
.treatment of scarlet fever, and, just as there were some cases of 
the latter affection so mild as to need no treatment, so there 
were cases of syphilis that could fall under the same category. 
It was absurd, in his opinion, to continue a mercurial treatment 
for two or three years in cases that were really so mild that, if 
left to themselves, they would end in recovery; but in defer- 
ence to custom he usually did continue the treatment for six 
months after the symptoms had disappeared. His opinion was, 
however, that in the severer forms it was better simply to treat 
the symptoms as they arose. In the stage of efflorescence 
iodide of potassium had no curative value and should never be 
continued for a long period. He considered that great harm 
could be done by giving too much of this drug, as several phy- 
sicians had reported cases where the symptoms of iodism were 
substituted for those of syphilis. Where no good results were 
noted from the use of this remedy harm was almost sure to fol- 
low, and then it would have been much better had the money 
thus thrown away been expended in beefsteak and country air. 

Dr. "William H. Portek remarked that his conclusions, de- 
duced from both clinical observation and experience in the post- 
mortem room, were that, in a very much larger proportion than 
was commonly supposed to be the case, of the patients suffering 
from diseases of the viscera, an initial syphilitic lesion could be 
discovered. This was peculiarly the case with the cerebro- 
spinal system, lungs, liver, and kidneys. He was decidedly in 
favor of mercury in the treatment of this affection, but did not 
consider very large doses of the iodide necessary. It was very 
necessary to give calomel or podophyllin frequently, however, 
in order to have a free and frequent action upon the liver; he 
considered this particularly important in the inherited forms. 
He was in favor of combining the mercury and iodide of potas- 
sium, and had found that the iodide of ammonium had an effect, 
apparently not from any inherent curative power, but because 
it seemed to act in very much the same way as trituration did 
with calomel, increasing the power of the combined drugs so 
that the same result was obtained from smaller doses than 
when the ammonium was not employed. lie had obtained 
quite as good results from one sixteenth of a grain of the binio- 
dide of mercury, fifteen grains of the iodide of potassium, and 
five grains of the iodide of ammonium at a dose, when sixty, 
eighty, or even one hundred grains of the saturated solution of 



the iodide of potassium had failed. If by combining these sub- 
stances a small dose would effect the same result as the larger 
one, it was of course better. 

Dr. G. B. Hope had seen cases of so-called cured syphilis 
where the initial lesions had disappeared and the later symp- 
toms had been absent for years, but where ulcerations of the 
throat and larynx existed of such a character as to be at once 
serious and dangerous. These cases yielded more readily to 
treatment when internal medication with mercury and the 
iodide of potassium rather than topical applications was em- 
ployed. He had found that iodoform could be elegantly pre- 
pared, and, when combined with morphine powder and used as 
a local application, gave great relief. 

Dr. D. B. St. J. Roosa remarked that, as his chief interest 
lay rather in general medicine and surgery than in the specialty 
into which the circumstances of his life had directed him, he 
preferred speaking on the subject from that standpoint. He 
had been particularly interested in the discussion because it 
indicated that the therapeutics of syphilis was approaching a 
standard of correctness which was hardly comparable with the 
iron-clad notions which formerly obtained regarding the efficacy 
of drugs in the treatment of this affection. If it should ever be 
his misfortune to be inoculated with this disease, he would pre- 
fer to put himself into the hands of a good cook and house- 
keeper, with country air and plenty of exercise, to trusting to the 
empirical remedies applied by many physicians whom he could 
designate. The homoeopathic theory, which considered all dis- 
ease a beast, to be hunted out by so